Federal inspection record · CMS data as of October 1, 2026
Avantara Norton
3600 South Norton Avenue, Sioux Falls, SD · (605) 338-9891
- Cited for abuse (CMS abuse icon)
- Special Focus Facility
- Certified beds
- 110
- Residents per day
- 97
- Ownership
- For-Profit
- Chain
- Legacy Healthcare
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- April 1, 1989
3
What inspectors found
75 health citations on record since 2023. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (19)
-
G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
-
G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
-
G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
-
G
Provide safe, appropriate pain management for a resident who requires such services.
-
G
Ensure that residents are free from significant medication errors.
-
G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
-
G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
-
G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
-
G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
-
H
Honor each resident's preferences, choices, values and beliefs.
-
G
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
-
G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
-
G
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
-
G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
-
G
Provide safe, appropriate pain management for a resident who requires such services.
-
K
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
-
H
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
-
H
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
-
H
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Everything else, by area of care
Resident Rights12E
- E
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
- D
Prepare residents for a safe transfer or discharge from the nursing home.
- E
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- D
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
- E
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
- E
Honor the resident's right to organize and participate in resident/family groups in the facility.
- E
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
- E
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Resident Assessment and Care Planning12E
- E
Ensure each resident receives an accurate assessment.
- E
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
- D
Ensure services provided by the nursing facility meet professional standards of quality.
- E
Ensure services provided by the nursing facility meet professional standards of quality.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
- D
Ensure services provided by the nursing facility meet professional standards of quality.
- E
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Quality of Life and Care8E
- E
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
- D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- E
Provide safe and appropriate respiratory care for a resident when needed.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- E
Provide enough food/fluids to maintain a resident's health.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Nutrition and Dietary7F
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- D
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- E
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
- E
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Freedom from Abuse, Neglect, and Exploitation5D
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- D
Protect each resident from the wrongful use of the resident's belongings or money.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Infection Control4E
- D
Provide and implement an infection prevention and control program.
- E
Provide and implement an infection prevention and control program.
- E
Provide and implement an infection prevention and control program.
- D
Provide and implement an infection prevention and control program.
Administration4F
- E
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
- E
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
- F
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
- F
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Pharmacy Service3E
- E
Ensure that residents are free from significant medication errors.
- E
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
- E
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Nursing and Physician Services1D
- D
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspection history
2026-03-31
21 health deficiencies · 0 fire-safety deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
2025-03-05
20 health deficiencies · 1 fire-safety deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
2023-11-09
34 health deficiencies · 0 fire-safety deficiencies
Top issue: Resident Rights (8 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 4 h 1 min of nursing staff time a day, 45 min of it from a registered nurse.
This home
4 h 1 min
South Dakota average
3 h 51 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 61% of nursing staff and 56% of registered nurses left in the past year.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Fines and payment denials
$283,633 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2026-03-31 | Fine | $96,750 |
| 2026-02-04 | Fine | $61,845 |
| 2025-03-05 | Fine | $51,376 |
| 2024-09-26 | Fine | $12,035 |
| 2024-07-17 | Fine | $12,035 |
| 2024-06-20 | Fine | $12,035 |
| 2024-03-13 | Fine | $37,557 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days0.3 pts worse | 1.8 | 1.5 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days1.2 pts worse | 2.9 | 1.7 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine1.9 pts better | 96.8% | 94.9% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine1.6 pts better | 98.8% | 97.2% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury2.3 pts better | 3.2% | 5.5% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms11.9 pts worse | 17.8% | 5.9% | 13.5% |
| Percentage of long-stay residents who lose too much weightAbout the same | 5.7% | 5.7% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication0.4 pts better | 17.3% | 17.7% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication12.4 pts better | 12.4% | 24.8% | 15.4% |
| Percentage of long-stay residents who were physically restrainedAbout the same | 0.0% | 0.0% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened11.3 pts worse | 29.6% | 18.3% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased6.9 pts worse | 28.4% | 21.5% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder1.6 pts worse | 3.5% | 1.9% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection2.7 pts worse | 5.6% | 2.9% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence4.9 pts worse | 29.4% | 24.5% | 18.3% |
| Percentage of long-stay residents with pressure ulcers1.6 pts worse | 6.1% | 4.5% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine1.3 pts better | 85.2% | 83.9% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit1.3 pts worse | 14.6% | 13.3% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication0.6 pts better | 1.6% | 2.2% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine5.6 pts better | 81.1% | 75.5% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission4 pts worse | 24.0% | 20.0% | 23.4% |
·
Who owns and runs it
19 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Doros Generation Trust U/A/D 1/3/12 | 5% Or Greater Direct Ownership Interest · Organization | 43% | 76 facilities |
| Gpn Family Trust U/A/D 4/28/08 | 5% Or Greater Direct Ownership Interest · Organization | 43% | 80 facilities |
| Oakway Operations LLC | 5% Or Greater Direct Ownership Interest · Organization | 15% | 46 facilities |
| Bokf,na | 5% Or Greater Security Interest · Organization | 0% | 13 facilities |
| Bokf,na | Operational/Managerial Control · Organization | 0% | 13 facilities |
| Doros Generation Trust U/A/D 1/3/12 | Adp Of The SNF · Organization | 0% | 76 facilities |
| Gpn Family Trust U/A/D 4/28/08 | Adp Of The SNF · Organization | 0% | 80 facilities |
| Legacy Healthcare Financial Services LLC | Operational/Managerial Control · Organization | 0% | 78 facilities |
| Legacy Healthcare Financial Services LLC | Adp Of The SNF · Organization | 0% | 78 facilities |
| Nickel, Ashley | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Nickel, Ashley | Adp Of The SNF · Individual | 0% | 1 facilities |
| Norton Sd Property Holdings, LLC | 5% Or Greater Security Interest · Organization | 0% | 1 facilities |
| Norton Sd Property Holdings, LLC | Adp Of The SNF · Organization | 0% | 1 facilities |
| Rees, Joseph | Operational/Managerial Control · Individual | 0% | 4 facilities |
| Rees, Joseph | Adp Of The SNF · Individual | 0% | 4 facilities |
| Roth & Co, Llp | Adp Of The SNF · Organization | 0% | 41 facilities |
| Shabat, Menachem | Managing Control - Governing Body · Individual | 0% | 86 facilities |
| Shabat, Menachem | Operational/Managerial Control · Individual | 0% | 86 facilities |
| Shabat, Menachem | Adp Of The SNF · Individual | 0% | 86 facilities |
·
Fire safety
1 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Emergency Preparedness1D
- D
Develop and maintain an Emergency Preparedness Program (EP).
·
Other homes nearby
-
Good Samaritan Society Luther Manor
Sioux Falls, SD · Good Samaritan Society
★★★★★- Worst citation, 3 yrs
- G
- Nursing / resident / day
- 4 h 9 min
- Fines
- $111,701
-
Bethany Home Sioux Falls
Sioux Falls, SD
★★★★★- Worst citation, 3 yrs
- F
- Nursing / resident / day
- —
- Fines
- $0
-
Avera Prince Of Peace
Sioux Falls, SD · Avera Health
★★★★★- Worst citation, 3 yrs
- G
- Nursing / resident / day
- 5 h 59 min
- Fines
- $8,278