Avantara Arrowhead: Accident Hazard Harm - SD
Federal inspectors cited the facility for causing actual harm to residents after reviewing the lift system's operating manual, dated October 2020. The language was direct. All residents must always be securely safety belted at the waist when using any of the lift systems, the manual stated on page seven. Not sometimes. Not when circumstances allow. Always.
The facility's own certified nursing assistant job description, in place since December 2019, required staff to follow established safety precautions when performing tasks and using equipment. That document predated the lift manual by nearly a year. The expectation had been written down in two separate places.
It didn't matter.
The inspection, triggered by a complaint, was completed in November 2025. Inspectors classified the violation at a level of actual harm, meaning the failure wasn't a paperwork problem or a procedural gap on paper. Someone was hurt.
Mechanical lifts exist because transferring a resident from a bed to a wheelchair, or from a chair to a shower, carries real risk. The belts are the margin between a controlled transfer and a fall. When that margin is removed, the resident bears the consequences.
The facility had written the rule. The facility had trained staff to follow safety precautions. None of it closed the distance between what the manual required and what happened in that room.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avantara Arrowhead from 2025-11-06 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
AVANTARA ARROWHEAD in RAPID CITY, SD was cited for violations during a health inspection on November 6, 2025.
Federal inspectors cited the facility for causing actual harm to residents after reviewing the lift system's operating manual, dated October 2020.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.