Christian City Rehab: Accident Hazard Failures - GA
The resident, identified in inspection records only as R1, had asked to use a bedside commode. CNA DD was the only staff member assigned to her care. According to CNA DD's account, she asked R1 to stand with her hands on the bed so she could be cleaned, and that's when R1's legs gave out. She fell to her knees, ending up in what a nurse later described as a prayer position on the floor. CNA DD called for help. Six staff members came to the room to get her back into bed.
R1 complained of pain in her lower extremities. Imaging was ordered and performed, and no injuries were documented.
CNA DD told inspectors she believed R1 required only one person for transfers before November 6. The care plan, she said, was updated to require two-person assistance after the fall. But the facility's director of nursing and administrator confirmed to inspectors that the two-person requirement had already been in place since October 29, three weeks before the fall occurred.
The gap between what the care plan said and what CNA DD understood it to say was never explained in the inspection record.
R1 was discharged from the facility on November 9, three days after the fall. The director of nursing confirmed the discharge was due to respiratory distress, not injuries from the fall.
Federal inspectors cited the facility under F0689, which covers accident hazards and supervision, and rated the level of harm as minimal or potential. The inspection was conducted in response to a complaint and completed November 21, 2025.
Six people standing around a resident on her knees is not a close call. It is what a preventable fall looks like after it has already happened.
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 6, 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 to use 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.