Colonial Vista: PICC Line Infection Control Failures - WA
The resident, identified as Resident 79, was admitted with endocarditis, a potentially life-threatening infection of the heart's inner lining, and required a PICC line for antibiotic therapy. PICC lines are central venous catheters inserted through arm veins to deliver medications directly to the heart, making sterile technique essential to prevent bloodstream infections that could prove fatal for someone already fighting heart infection.
On August 21 at 4:27 PM, inspectors observed Staff H, a registered nurse, perform the PICC line dressing change. The nurse began appropriately by performing hand hygiene, putting on gloves, and cleaning the resident's bedside table with a disinfecting wipe.
But the procedure quickly deteriorated.
After disposing of the used wipe and gloves, Staff H opened the sterile dressing supply package without performing hand hygiene first, then washed their hands. The nurse placed surgical masks on both the resident and themselves, put on new gloves, and positioned a sterile drape under the resident's arm.
Staff H removed the old dressing and gloves, tossing them in the trash. Without washing hands again, the nurse put on sterile gloves and measured the PICC line length and the resident's arm circumference.
Then Staff H reached into their pants pocket with the sterile gloves.
The nurse pulled out a pen, wrote measurements on the sterile drape, and put the pen back in their pocket. After cleaning around the PICC opening with an antiseptic swab and attaching a line holder to the resident's arm, Staff H reached into their pocket again with the contaminated sterile gloves, retrieved the pen, and placed it on the bedside table.
The nurse applied barrier adhesive and a clear dressing over the PICC site, used the pen to write the date and initials on the dressing, then reached into their pocket a third time to get an alcohol swab. Staff H removed the old PICC cap access device and attached a new one before finally gathering supplies, removing gloves, and washing hands.
When confronted by inspectors, Staff H admitted the violations. The nurse acknowledged placing hands into pockets during the dressing change while wearing sterile gloves and said they should not have done so. Staff H also stated they were unaware they had failed to perform hand hygiene between glove changes and when opening the sterile supply package.
The facility was simultaneously dealing with a COVID-19 outbreak that exposed additional infection control failures. Federal guidelines require nursing homes to test all residents and staff who previously tested negative every three to seven days for a minimum of 14 days following the most recent positive case.
During an interview on August 20, Staff K, a regional nurse, stated they were unaware additional residents had tested positive for COVID-19. Staff K said that if they had known, the facility should have continued testing according to federal guidelines.
The PICC line contamination represented a particularly serious breach because Resident 79's compromised immune system from endocarditis made them extremely vulnerable to additional infections. The comprehensive assessment from July 24 showed the resident required substantial assistance from one to two staff members for daily activities but had intact cognition, meaning they were likely aware of the care being provided.
Staff B, the Director of Nurses, told inspectors on August 22 that Staff H had not followed proper steps for PICC line dressing changes. Staff B said they would provide re-education on proper technique.
PICC lines carry inherent infection risks even with perfect sterile technique. The Centers for Disease Control estimates that central line-associated bloodstream infections occur in 1 to 3 percent of PICC lines, with mortality rates ranging from 12 to 25 percent. For patients already fighting heart infections, additional bloodstream contamination can overwhelm the body's ability to respond to treatment.
The inspection found violations of Washington state regulations requiring nursing homes to follow accepted standards of practice for infection prevention and control. The state cited the facility under regulations mandating that nursing homes ensure staff follow proper procedures to prevent the spread of infection and disease.
Federal inspectors determined the violations caused minimal harm or potential for actual harm to few residents. But for Resident 79, fighting endocarditis with a compromised immune system, the contaminated sterile procedure represented a direct threat to recovery from an already serious condition.
The facility's infection control failures extended beyond individual patient care to systemic COVID-19 testing protocols, suggesting broader challenges in maintaining the vigilant hygiene practices that protect vulnerable residents from life-threatening infections.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Colonial Vista Post-acute & Rehab Center from 2025-08-22 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 20, 2026 · Our methodology
COLONIAL VISTA POST-ACUTE & REHAB CENTER in WENATCHEE, WA was cited for violations during a health inspection on August 22, 2025.
On August 21 at 4:27 PM, inspectors observed Staff H, a registered nurse, perform the PICC line dressing change.
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.