SPARTA, GA - State health inspectors documented serious safety violations at Providence of Sparta Health and Rehab during an August 2024 inspection, including an incident where a resident was burned during physical therapy treatment and multiple failures in infection control protocols.
Physical Therapy Treatment Results in Resident Burn
The most serious violation involved a resident who received severe burns during electrical stimulation therapy, a common physical therapy treatment that uses electrical impulses to stimulate muscles and reduce pain. The incident occurred on June 5, 2024, when physical therapy staff applied an e-stim device to a resident's right leg and left the room during treatment.
According to the inspection report, the resident stated that "after about 15 or 20 minutes, the areas where the device was applied began to burn him like crazy, so he removed the pads from his leg." The resident discovered three burn marks, with one area being particularly severe. Medical records showed the burn measured 5 x 5 x 1 millimeters with 100% slough in the wound bed, indicating complete tissue death.
The facility's own operational manual clearly stated that electrical stimulation should not be used "on open wounds or rashes, or over swollen, red, infected, or inflamed areas" and warned against use "over areas of skin that lack normal sensation." The resident had a documented history of Type 2 diabetes with diabetic neuropathy, a condition specifically listed as a contraindication for e-stim treatment.
Critical Communication Breakdown
The inspection revealed a serious breakdown in communication protocols. Physical therapy staff failed to immediately notify nursing staff about the burn, and medical providers weren't informed until 11 days after the incident. Most concerning, the resident received another e-stim treatment on June 13 - eight days after the burn was discovered - because staff failed to communicate the injury.
Physical therapy staff admitted they received no formal training on the e-stim device from the facility. One Physical Therapy Assistant revealed she "applied the device on herself to figure it out" before using it on residents. Another staff member stated she "had to go home and look up the operation of the device online."
Respiratory Care Failures Create Risk
Inspectors documented failures in respiratory care that put vulnerable residents at risk of breathing complications and infections. One resident with chronic respiratory conditions had a physician's order for continuous oxygen at 2 liters per minute, but observations revealed the oxygen tubing was repeatedly found "lying across the bed rail exposed to the environment" while the resident was not receiving oxygen.
The resident's medical history included acute and chronic respiratory failure, heart failure, and chronic obstructive pulmonary disease (COPD) - conditions that make adequate oxygenation critical for preventing respiratory distress and organ damage. When respiratory tissues don't receive adequate oxygen, it can lead to worsening heart failure, cognitive impairment, and potentially life-threatening complications.
Inspectors also found improper storage of nebulizer equipment used to deliver breathing medications. The nebulizer mouthpiece for another resident with COPD was found "lying on the bed, unbagged and exposed to the environment" for multiple days. This creates significant infection risk, as contaminated respiratory equipment can introduce bacteria directly into the lungs, potentially causing pneumonia or other serious respiratory infections.
Industry Standards Require Strict Protocols
Professional respiratory care standards require oxygen delivery devices to be kept covered when not in use and nebulizer equipment to be stored in sealed bags between treatments. These protocols prevent contamination from environmental bacteria and ensure equipment remains sterile for the next use. The facility's own policies required these safety measures but were not being followed.
Electrical Safety Hazards Throughout Facility
The inspection identified widespread electrical safety violations that created trip hazards and potential shock risks. Power strips and surge protectors were found unsecured on floors and bedside tables throughout the facility, with critical medical equipment like oxygen concentrators and hospital beds plugged into them.
In three different residents' rooms, inspectors observed power strips on the floor with medical equipment connected. The Maintenance Director acknowledged that surge protectors should be wall-mounted because floor placement creates trip hazards, but stated he "didn't have time to mount the surge protectors" even after being notified of the problem.
One resident reported that a power strip had been on his floor "for over a week" after maintenance work in his bathroom, creating an ongoing safety hazard. This violates basic electrical safety standards and creates risks for elderly residents who may have mobility limitations or visual impairments.
Food Safety and Kitchen Operations
Multiple food safety violations were documented in the facility's kitchen operations. Staff failed to follow established menus, substituting ingredients without notifying the registered dietitian. For example, when the menu called for fried chicken, kitchen staff served plain steamed chicken with brown gravy instead, compromising the nutritional value residents were supposed to receive.
The facility's three-compartment sink, essential for proper dish sanitization, was not being used correctly. Staff were observed sanitizing equipment for only seconds instead of the required 60-second minimum contact time needed to kill harmful bacteria. This creates serious risk for foodborne illness among vulnerable elderly residents.
Additional violations included food stored directly on floors instead of elevated surfaces, wet-nesting of steam table pans that promotes bacterial growth, and a dumpster with a missing drain plug that leaked liquid waste onto the ground for three consecutive days.
Medical Context: Why These Violations Matter
These violations are particularly serious in nursing home settings because residents often have compromised immune systems, chronic medical conditions, and limited ability to advocate for themselves. Elderly residents are at higher risk for infections, have slower healing processes, and may have difficulty communicating problems.
Electrical stimulation burns can be especially dangerous for diabetic patients because their reduced sensation may prevent them from feeling pain that would normally alert them to injury. Poor wound healing associated with diabetes can lead to serious complications including infection and tissue death.
Respiratory equipment contamination poses significant risks for residents with COPD and other lung diseases, as their already-compromised respiratory systems cannot effectively fight off additional infections. Inadequate oxygen delivery can rapidly worsen existing heart and lung conditions.
Additional Issues Identified
The inspection also documented failures in care plan updates, with one resident's care plan not reflecting a change from full resuscitation to "Do Not Resuscitate" status. Additionally, infection control protocols were not properly followed in the laundry, with staff handling soiled linens without protective equipment and transporting clean linens without proper covering.
Staff training deficiencies extended beyond the physical therapy department, with laundry and dietary staff demonstrating lack of knowledge about basic infection control and food safety procedures required for their positions.
The facility has 30 days to submit a plan of correction addressing each violation and demonstrating how they will prevent similar incidents in the future.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Providence of Sparta Health and Rehab from 2024-08-11 including all violations, facility responses, and corrective action plans.
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