Avina on Division: PICC Line Monitoring Failures - WI
The discrepancy, documented during an April 30, 2026 complaint inspection, exposed a more fundamental problem: the facility had been calling the catheter the wrong thing entirely.
The resident, identified in inspection records only as R2, had been receiving IV antibiotics through a midline catheter. Staff at the facility, including the director of nursing, referred to it throughout as a PICC line. The distinction matters. A PICC line, or peripherally inserted central catheter, is threaded deep into a large vein near the heart. A midline catheter is shorter, ending in a vein in the upper arm. They require different monitoring, different flushing protocols, and different expectations for what the catheter should look like at the skin.
The director of nursing, identified in inspection records as DON-B, told the surveyor on April 29 that DON-B had measured R2's external catheter length during a dressing change but had no place to document it. DON-B said the measurement would be provided along with the original placement paperwork.
The next day, at noon, DON-B returned with a number: 10 centimeters without the hub, 14 centimeters with it.
Twenty minutes later, the surveyor read the placement document DON-B had just handed over. The external catheter length listed at placement was 0 centimeters.
At 12:26 p.m., the surveyor called the infusion clinic named at the bottom of that document and spoke with a registered nurse, identified as RN-E, who had placed the catheter. RN-E said immediately that R2 had a midline catheter, not a PICC line, and that a midline catheter's correct external length is 0 centimeters. If any external length was visible, RN-E said, the catheter was likely migrating out of the vein. The way to check: small hash marks printed on the catheter line, each representing one centimeter, would become visible at the skin.
Thirteen minutes later, the surveyor examined R2's catheter directly. A stat lock held the line against R2's skin beneath a transparent dressing, with a 2x2 gauze pad over the insertion site. The catheter itself was labeled "midline catheter." No hash marks were visible. No redness, swelling, or leaking fluid appeared under the dressing.
When the surveyor told DON-B that afternoon what RN-E had explained, DON-B's account shifted. DON-B now said the external catheter length was, in fact, 0 centimeters, and that DON-B had not seen any hash marks during the dressing change the day before.
The inspection record noted that progress notes for R2 showed no signs or symptoms of infection or leaking at the catheter site, and the harm level was classified as minimal, with few residents affected.
But the inspection also documented that R2 had no physician order for saline flushes, which RN-E said were needed every 24 hours and before and after each infusion to prevent the catheter from clogging. DON-B confirmed to the surveyor that a physician order was required before any flushes could be given, and that no such order existed.
What the record shows is a nursing home managing a resident's IV antibiotic treatment without correctly identifying the type of catheter in use, without a flushing order, and with a director of nursing who measured an external length that, by the placement clinic's own documentation, should not have existed. When the surveyor produced that documentation, the measured length disappeared from DON-B's account.
R2's catheter showed no visible signs of harm on April 30. Whether the missing flush orders or the confusion about catheter type affected R2's treatment in the days before the inspection, the records reviewed by the surveyor did not resolve.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avina On Division from 2026-04-30 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
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.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 7, 2026 · Our methodology
Avina on Division in Fond du Lac, WI was cited for violations during a health inspection on April 30, 2026.
The resident, identified in inspection records only as R2, had been receiving IV antibiotics through a midline catheter.
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.