Christian City Rehab: Care Plan Failures - GA
The resident, identified in inspection records only as R1, had asked for a bedside commode. CNA DD, the only staff member assigned to her care at the time, was cleaning her when the resident's legs gave out. She dropped to the floor in what a nurse on the scene later described as a "prayer position." Six staff members crowded into the room to get her back into bed.
CNA DD told inspectors she believed R1 needed only one person for transfers before that day, and that the care plan was updated to require two people only after the fall. The Director of Nursing and the facility's administrator told inspectors that was wrong. R1 had been care-planned for two-person transfers since October 29, more than a week before she fell.
CNA DD said she checks the care plan to determine staffing requirements for transfers. So did another nursing assistant interviewed that day. The care plan said two people. One showed up.
R1 complained of pain in her lower extremities after the fall. Imaging was ordered and performed. No injuries were found. She was discharged from the facility three days later, on November 9, in respiratory distress unrelated to the fall, according to the Director of Nursing and the administrator.
Inspectors rated the violation at the minimal harm level. The inspection was conducted on November 21 in response to a complaint.
What the records don't resolve is whether anyone told CNA DD, before November 6, that the transfer requirement had changed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Christian City Rehabilitation Center from 2025-11-21 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: August 7, 2026 · Our methodology
CHRISTIAN CITY REHABILITATION CENTER in UNION CITY, GA was cited for violations during a health inspection on November 21, 2025.
The resident, identified in inspection records only as R1, had asked for a bedside commode.
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.