Robert Lee Care Center: Unsafe Transfer Violations - TX
A physical therapist assistant told inspectors she witnessed aides transferring residents by hooking under their arms, a method she said could hurt shoulders. The facility's physical therapist explained that safe two-person transfers required one person in front and one behind the resident, controlling the movement from the hips using a gait belt.
"Aides did not want to lift residents by the shoulders because the aides needed more control and it was not safe," the physical therapist said. "Aides needed to be careful with the arms because it could pull or dislocate the arm."
The director of nursing acknowledged that hooking under residents' arms was uncomfortable and could cause skin tears and bruising. She said grabbing residents by their waistbands "could cause a wedgie and was not comfortable."
When two nursing aides demonstrated proper technique for inspectors, they used gait belts around the waist and held the director's forearms during transfers. The director confirmed this was how staff were trained to perform the maneuver.
The facility had conducted skills training in May 2025 that included mechanical lifting and hands-on demonstration. Staff were instructed not to pull or tug on residents' arms, and the director said the purpose of gait belts was to slow down falls.
However, transfers were not continuously monitored. The assistant director of nursing and charge nurses were responsible for oversight, but the assistant director was on vacation and unreachable during the inspection.
The facility's 2017 policy required appropriate techniques to protect both staff and resident safety, incorporating resident dignity, comfort and medical condition into transfer decisions.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Robert Lee Care Center from 2025-12-31 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 21, 2026 · Our methodology
ROBERT LEE CARE CENTER in ROBERT LEE, TX was cited for violations during a health inspection on December 31, 2025.
A physical therapist assistant told inspectors she witnessed aides transferring residents by hooking under their arms, a method she said could hurt shoulders.
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.