Robert Lee Care Center

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #31) reviewed for care plans. The facility failed to implement a comprehensive person-centered care plan that addressed Resident #31's behaviors.

This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans developed to address their needs.Findings included: Record review of Resident #31's face sheet dated 12/31/25, revealed admission on [DATE REDACTED] to the facility. Diagnoses included dementia with psychotic disturbance, delusions, hallucinations, and depression. Record review of Resident #31's quarterly MDS dated [DATE REDACTED], revealed a BIMS score of 2 indicating severe cognitive impairment and disorganized thinking was also coded in this section. Mood was not coded. Behaviors section E - Rejection of care and wandering were both coded as a 1 which indicated these behaviors occurred 1 to 3 days during this look back period. Record review of Resident #31's Care Plan dated 4/16/2025, revealed there was no focus, goal, or intervention section for Resident #31's history of wandering or rejection of care. During an interview on 12/31/25 at 1:45 PM, with the DON she stated these behaviors should have been care planned because it was part of the resident's behavior and needed to be documented. The DON stated the MDS department was responsible for ensuring that it was care planned.

The DON stated the purpose of the care plan was to provide the care for the resident and for everyone to know what the resident needed. The DON stated that it was necessary for the care of the resident. During

an interview on 12/31/25 at 2:29 PM, with the MDS coordinator, she stated it was the responsibility of the MDS department to ensure the care plans were correct. The MDS coordinator stated there was no wandering or rejection of care, care planned for Resident #31. The MDS coordinator stated it should have been care planned for Resident #31's wandering to be able to keep an eye on her. The MDS coordinator stated the purpose of the care plan was to notify the staff of Resident #31's behaviors. The MDS coordinator stated the risk could be needs not being met. Record review of the facility Care Planning policy dated 03/2022, revealed 1. The IDT in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.7.

The comprehensive person-centered care plan:b. Describes the services that are to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/31/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Robert Lee Care Center

307 West 8th St Robert Lee, TX 76945

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

sure about the consequences, but it could hurt the shoulder. PTA E stated she did see the aides transfer by hooking under the arms. PTA E said she did not usually transfer residents by the waistband of their pants.

Interview on 12/31/2025 at 10:02 AM the PT stated a safe two-person gait-belt transfer looked like someone in front of the resident and someone behind the resident controlling the transfer from the resident's hips. The PT stated the therapy department did not do specific training with the aides on how to do a transfer, but they did talk to the aides constantly about what kind of transfer a resident needed. The PT said aides did not want to lift residents by the shoulders because the aides needed more control and it was not safe. The PT said aides needed to be careful with the arms because it could pull or dislocate the arm.

The PT said using the gait belt in front and grabbing the waistband was not the safest and did not give enough control. Interview on 12/31/2025 at 10:21 AM the DON stated the facility did train aides to complete

a two person gait belt transfer. The DON stated they trained the staff to have one staff in front and one staff behind to assist with the stand and pivot maneuver. Observation on 12/31/2025 at 10:27 AM CNA C and CNA D demonstrated a two-person gait-belt transfer on the DON. The CNAs placed the gait belt around DON's waist. Each held the gait-belt in the back and assisted the DON to stand by holding the DON's forearm. The CNAs completed the sitting transfers also by holding the DON's forearm. Interview on 12/31/2025 at 10:29 AM the DON stated the ADON did train the aides to complete the transfer that way.

The DON said the ADON was out of town on vacation and unable to be reached. The DON said aides were instructed not to pull or tug on the residents' arms. The DON said hooking an arm under the resident's arm was uncomfortable could cause skin tears and bruising and it was not a safe transfer. The DON stated grabbing a resident by the waistband could cause a wedgie and was not comfortable. The DON said the consequence of holding a resident under the arm could cause injury like skin tears or bruising. The DON said the facility did a skills fair training where they checked aides off on two-person gait-belt transfers. The DON said the purpose of the gait belt was to slow down a fall. The DON said transfers were not continuously monitored. The DON said the ADON and charge nurses were responsible for keeping an eye

on transfers. Review of the facility's policy and procedure on Safe Lifting and Movement of Residents, revised 7/2017, revealed: In order to protect the safety and wellbeing of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents.Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. Review of the Training Inservice Summary for Skills Fair, completed 5/27/25, revealed the facility in-serviced staff for annual compliance and competency training. CNAs were trained in mechanical lifting and incontinent care. Methodology included lectures, handouts, and demonstration with a hands on skills training.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/31/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Robert Lee Care Center

307 West 8th St Robert Lee, TX 76945

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

under a resident's arm was not supposed to be done during transfers. PTA E said she was not sure about

the consequences, but it could hurt the shoulder. PTA E stated she did see the aides transfer by hooking under the arms. PTA E said she did not usually transfer residents by the waistband of their pants. Interview

on 12/31/2025 at 10:02 AM the PT stated a safe two-person gait-belt transfer looked like someone in front of the resident and someone behind the resident controlling the transfer from the resident's hips. The PT stated the therapy department did not do specific training with the aides on how to do a transfer, but they did talk to the aides constantly about what kind of transfer a resident needed. The PT said aides did not want to lift residents by the shoulders because the aides needed more control and it was not safe. The PT said aides needed to be careful with the arms because it could pull or dislocate the arm. The PT said using

the gait belt in front and grabbing the waistband was not the safest and did not give enough control.

Interview on 12/31/2025 at 10:21 AM the DON stated the facility did train aides to complete a two person gait belt transfer. The DON stated they trained the staff to have one staff in front and one staff behind to assist with the stand and pivot maneuver. Observation on 12/31/2025 at 10:27 AM CNA C and CNA D demonstrated a two-person gait-belt transfer on the DON. The CNAs placed the gait belt around DON's waist. Each held the gait-belt in the back and assisted the DON to stand by holding the DON's forearm. The CNAs completed the sitting transfers also by holding the DON's forearm. Interview on 12/31/2025 at 10:29 AM the DON stated the ADON did train the aides to complete the transfer that way. The DON said the ADON was out of town on vacation and unable to be reached. The DON said aides were instructed not to pull or tug on the residents' arms. The DON said hooking an arm under the resident's arm was uncomfortable could cause skin tears and bruising and it was not a safe transfer. The DON stated grabbing

a resident by the waistband could cause a wedgie and was not comfortable. The DON said the consequence of holding a resident under the arm could cause injury like skin tears or bruising. The DON said the facility did a skills fair training where they checked aides off on two-person gait-belt transfers. The DON said the purpose of the gait belt was to slow down a fall. The DON said transfers were not continuously monitored. The DON said the ADON and charge nurses were responsible for keeping an eye

on transfers. Review of the facility's policy and procedure on Safe Lifting and Movement of Residents, revised 7/2017, revealed: In order to protect the safety and wellbeing of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents.Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. Review of the Training Inservice Summary for Skills Fair, completed 5/27/25, revealed the facility in-serviced staff for annual compliance and competency training. CNAs were trained in mechanical lifting and incontinent care. Methodology included lectures, handouts, and demonstration with a hands on skills training.

Event ID:

Facility ID:

If continuation sheet