Avantara Norton: Forced Shower, Delayed Abuse Report - SD
The incident at Avantara Norton occurred on May 27 when the aide woke the resident at 7:10 a.m. and demanded she shower because she had urinated on herself. The resident refused. The aide gave her a shower anyway.
According to the resident's account, certified nurse aide E was "rough with her" during the morning encounter. The aide "forced her to wake up" and "grabbed her by the arms and pushed her down into the chair" after demanding the shower.
The facility didn't learn about the incident until May 28, when the resident filed a written grievance form that reached Administrator A. The administrator reviewed the grievance at 11:22 a.m. and immediately suspended the aide pending investigation.
But federal regulations require nursing homes to report suspected abuse immediately. The one-day delay violated those rules, according to state inspectors who investigated the facility in June.
Administrator A told inspectors she expected to be "notified immediately regarding any potential abuse or neglect situations." She said her expectation would have been "to allow resident 1 to refuse the shower and to come back later or have a different staff member come back later to assist the resident."
The resident's care plan included specific preferences for showering and bathing that staff ignored during the May 27 incident. Federal inspectors found the facility violated the resident's right to refuse treatment when staff proceeded with the unwanted shower.
After receiving the grievance, Administrator A launched an investigation. She interviewed the resident about what happened and spoke with the aide to get her side of the story. She also interviewed other residents on the rehabilitation unit to determine if there were additional concerns about the aide's behavior.
The administrator questioned staff about their involvement in the incident and informed the director of therapy about the situation. She used the incident as a teaching moment, having the therapy director educate staff about "what to report, when to report, and who to report to."
Administrator A also provided reeducation to staff from all departments about the facility's abuse and neglect policy and reporting expectations. She told the staffing agency not to allow the aide to return to the facility.
During the June inspection, Administrator A denied receiving a text message from Licensed Practical Nurse D on May 27 regarding the incident. The inspection report doesn't elaborate on what that text might have contained or why it was relevant to the investigation.
The delayed reporting "potentially put residents at risk for further alleged abuse," according to federal inspectors. The failure to immediately report abuse allegations can delay protective interventions and allow problematic staff to continue working with vulnerable residents.
Avantara Norton submitted its incident report to the South Dakota Department of Health on May 28 at 11:22 a.m., the same time the administrator reviewed the resident's written grievance. The timing suggests the facility reported the incident as soon as leadership became aware of it, but questions remain about why frontline staff didn't escalate the concerns immediately.
The inspection revealed broader issues with the facility's reporting culture. Staff needed additional education about recognizing abuse and neglect situations and understanding their obligations to report concerns up the chain of command without delay.
Federal inspectors found the facility had implemented corrective actions by the time of their June 19-20 survey. The provider followed its quality assurance process and provided comprehensive education to all staff about abuse, neglect, and reporting requirements.
Inspectors reviewed educational materials and staff signature sheets confirming that employees had received and acknowledged the training. They interviewed staff from various departments including housekeeping, social services, nursing, and therapy to verify understanding of the new protocols.
The staff interviews revealed that employees now understood the education provided about abuse, neglect, and the reporting process. Based on these corrective actions, inspectors classified the violations as "past non-compliance," meaning the problems had been addressed.
The case highlights ongoing challenges in nursing home oversight and staff accountability. Even when facilities have policies requiring immediate reporting of suspected abuse, those policies are only effective if frontline staff understand and follow them.
The resident who experienced the forced shower was identified only as "Resident 1" in inspection documents. Her specific medical conditions and length of stay at the facility weren't disclosed in the publicly available records.
The aide involved in the incident was working through a staffing agency rather than as a direct employee of Avantara Norton. This arrangement is common in nursing homes facing staffing shortages, but can create additional challenges for supervision and accountability.
Agency staff may be less familiar with individual residents' care plans and preferences, as appears to have happened in this case. The aide proceeded with the shower despite the resident's refusal and without regard for her previously established bathing preferences.
The incident occurred during the morning shift, typically one of the busiest times in nursing homes as staff help residents with personal care, medications, and breakfast. Time pressures during these peak periods can contribute to staff taking shortcuts or ignoring resident preferences.
Avantara Norton operates at 3600 South Norton Avenue in Sioux Falls. The facility is part of a larger chain of nursing homes operating under the Avantara brand across multiple states.
The June inspection was conducted in response to a complaint, suggesting that concerns about the facility's practices had reached state regulators through other channels beyond the internal grievance process.
While inspectors found that the facility had addressed the immediate problems, the case serves as a reminder that nursing home residents retain fundamental rights even when they need assistance with daily activities. The right to refuse treatment, including personal care like bathing, remains protected regardless of a resident's physical or cognitive limitations.
The forced shower incident and delayed reporting represent violations that could have had more serious consequences if not addressed through the facility's eventual corrective actions and staff education efforts.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avantara Norton from 2024-06-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 13, 2026 · Our methodology
AVANTARA NORTON in SIOUX FALLS, SD was cited for abuse-related violations during a health inspection on June 20, 2024.
The incident at Avantara Norton occurred on May 27 when the aide woke the resident at 7:10 a.m.
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.
Frequently Asked Questions
- What happened at AVANTARA NORTON?
- The incident at Avantara Norton occurred on May 27 when the aide woke the resident at 7:10 a.m.
- How serious are these violations?
- These are very serious violations that may indicate significant patient safety concerns. Federal regulations require nursing homes to maintain the highest standards of care. Families should review the full inspection report and consider whether this facility meets their safety expectations.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in SIOUX FALLS, SD, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from AVANTARA NORTON or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 435039.
- Has this facility had violations before?
- To check AVANTARA NORTON's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.