Columbus Health and Rehab: PICC Line Safety Failures - WI
A PICC line, a peripherally inserted central catheter, delivers medication directly into a large vein near the heart. Improper flushing technique can introduce air, cause clotting, or push a blockage deeper into the bloodstream. One standard step, aspirating blood before flushing to confirm the line is open and correctly placed, was handled differently by every nurse the surveyor spoke with.
RN/MDS L said she was never taught to pull back for blood return. Not here, not during PICC line work, not even when she had administered chemotherapy through one. She said a colleague had walked her through the procedure informally after she started in June. She had completed an annual skills check, she said, but had no documented PICC line competency on file.
RN M knew to pull back for blood return. She said that's how she was trained at a hospital before coming to Columbus Health and Rehab. When the surveyor asked whether she had received any IV or PICC line training at this facility, she said no, not since she had been there.
RN D said she doesn't aspirate blood. She described a flushing sequence that skipped that step entirely. She recalled that a pharmacy representative had come out in the past to provide training, but said that hadn't happened recently.
The director of nursing, identified in the report as DON/IP B, described her own expected protocol when the surveyor asked: clean the hub, flush air bubbles from the syringe, attach to the needleless connector, flush in a pulsating motion, disconnect. She said she would not expect blood to be aspirated before medication administration.
That answer conflicts with published clinical guidance, which states that aspiration of blood should be attempted before flushing to ensure the line is patent.
When the surveyor asked DON/IP B how the facility ensures nurses are competent with PICC lines, she said there is a list of tasks that must be signed off within 30 days of hire, and that she personally watches nurses perform the task. The surveyor asked whether that observation is documented. DON/IP B said no.
She said competency is reviewed annually. She said she would expect staff to perform PICC line skills competently. She had nothing on paper to show that any of them had.
The inspection report notes that RN/MDS L was observed not following the facility's own policy and procedure for IV medications, and that she had no competency check on file for administering IV medication at all.
What emerges from the inspection is not a picture of a nurse who made an error. It is a picture of a facility where the nurses responsible for one of the more technically demanding procedures in long-term care were each working from a different mental model of how to do it, and where the person accountable for their training had no documentation that training had ever been verified.
The inspection was completed March 12, 2025. CMS rated the harm level as minimal or potential for actual harm, affecting few residents.
The residents with PICC lines at Columbus Health and Rehab during this period are not named in the inspection report. What happened to them, whether their lines were patent, whether medications reached their intended destination, whether anyone noticed a problem, the report does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Columbus Health and Rehab from 2025-03-12 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.
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Last verified: November 7, 2026 · Our methodology
Columbus Health and Rehab in Columbus, WI was cited for violations during a health inspection on March 12, 2025.
A PICC line, a peripherally inserted central catheter, delivers medication directly into a large vein near the heart.
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.