Robert Lee Care Center: Transfer Safety Failures - TX
The disagreement was not minor. When the facility's physical therapist described a safe two-person gait-belt transfer on December 31, 2025, she said one staff member should be in front of the resident and one should be behind, controlling the transfer from the resident's hips. She said grabbing the gait belt in front while holding the waistband was not safe and did not give enough control. She warned that careless handling of a resident's arms could pull or dislocate one.
Six minutes after the director of nursing described how aides had been trained, two CNAs demonstrated that training on the director herself. Both stood behind her, each gripping the gait belt in the back, and helped her stand by holding her forearm. That was not what the physical therapist had described.
The director of nursing said the assistant director of nursing had trained the aides on the technique the CNAs demonstrated. The ADON was out of town on vacation and could not be reached. The director said transfers were not continuously monitored, and that the ADON and charge nurses were responsible for keeping an eye on them.
The director also said the facility had held a skills fair in May 2025, where CNAs were checked off on two-person gait-belt transfers. The training records showed the skills fair covered mechanical lifting and incontinence care, with lectures, handouts, and hands-on demonstration. Whether the transfer technique practiced that day matched what the physical therapist described, or what the CNAs showed inspectors, the records did not say.
The physical therapist said the therapy department never did specific training with aides on how to complete a transfer. She said aides were told constantly what kind of transfer a resident needed, but not how to do it safely.
Inspectors cited the violation at the minimal harm level.
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.
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 19, 2026 · Our methodology
ROBERT LEE CARE CENTER in ROBERT LEE, TX was cited for violations during a health inspection on December 31, 2025.
The disagreement was not minor.
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.