Avantara Norton: Infection Control Violations - SD
SIOUX FALLS, SD - Avantara Norton nursing home faced significant citations from federal inspectors who documented widespread infection control failures affecting multiple residents, including improper hand hygiene during wound care and delayed implementation of enhanced barrier precautions for residents with catheters and wounds.
Critical Hand Hygiene Failures During Wound Care
Federal inspectors observed serious breaches of infection control protocols during wound care procedures involving two residents. During a dressing change for a resident with an abdominal wound, a certified nurse practitioner performed wound debridement, removed contaminated gloves, but failed to perform hand hygiene before putting on new gloves. The licensed practical nurse assisting touched the resident's blanket with gloved hands, then used those same contaminated gloves to open sterile supplies and apply medication to the wound.
In a separate incident involving a resident with leg wounds, the nurse practitioner again demonstrated poor hand hygiene practices. After removing soiled dressings, he changed gloves without performing hand hygiene, then proceeded to touch his iPad screen, reach into his pocket for surgical instruments, and handle photography equipment with contaminated gloves. When reminded by staff that the resident required enhanced barrier precautions due to open wounds, the practitioner applied a gown but continued using the same contaminated gloves for subsequent wound care procedures.
Hand hygiene represents the single most important measure for preventing healthcare-associated infections. When healthcare workers fail to properly sanitize their hands between procedures, they can transfer dangerous bacteria and other pathogens from contaminated surfaces to open wounds, significantly increasing infection risk. Proper protocol requires hand hygiene before and after all patient contact, before putting on gloves, and immediately after removing them.
Delayed Enhanced Barrier Precautions Implementation
The inspection revealed systematic delays in implementing enhanced barrier precautions (EBP) for residents requiring additional infection control measures. Four residents with conditions warranting EBP - including those with urinary catheters and open wounds - experienced delays ranging from four to 114 days before proper signage and protective equipment were placed outside their rooms.
One resident admitted with wounds requiring weekly dressing changes waited 114 days before EBP signage appeared on his door. Another resident admitted with a urinary catheter due to an enlarged prostate experienced a five-day delay before staff implemented proper precautions. A female resident with a post-surgical catheter waited seven days for EBP implementation.
"Staff told her they had to wear a gown now because of her urinary catheter," the resident explained to inspectors, noting the precautions had only begun the previous day.
Enhanced barrier precautions serve as a critical defense against multi-drug-resistant organisms in nursing home settings. These measures require healthcare workers to wear gowns and gloves during high-contact care activities for residents with indwelling devices like catheters or open wounds. Urinary catheters pose particular infection risks, as they provide a direct pathway for bacteria to enter the urinary tract. Without proper barrier precautions, staff can inadvertently spread resistant bacteria between residents during routine care.
Contaminated Personal Care Items and Storage Violations
Inspectors documented extensive problems with unlabeled and improperly stored personal care items throughout the facility. In shared rooms, residents' toothbrushes, razors, deodorant, syringes, and other personal items lacked proper identification, creating significant cross-contamination risks.
One shared bathroom contained three unmarked syringes, unlabeled wound cleanser, two toothbrush containers without resident identification, unmarked deodorant, and a razor with no identifying information. Under the sink, investigators found an unlabeled bedpan stored directly on the floor without proper containment.
Another room revealed similar violations, including an expired catheter insertion tray, unmarked mouthwash bottles, unidentified irrigation syringes, and various personal care items stored without proper labeling or contamination barriers. Medical supplies intended for sterile procedures were stored alongside personal items, increasing contamination risks.
Proper labeling and storage of personal care items prevents cross-contamination between residents and ensures items remain sanitary until use. When multiple residents share bathrooms and personal items lack identification, staff may inadvertently use one resident's contaminated items on another, potentially spreading infections including antibiotic-resistant bacteria, viruses, and other pathogens.
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 NORTON in SIOUX FALLS, SD was cited for violations during a health inspection on March 5, 2025.
In a separate incident involving a resident with leg wounds, the nurse practitioner again demonstrated poor hand hygiene practices.
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.