Robert Lee Care Center
ROBERT LEE CARE CENTER in ROBERT LEE, TX — inspection on December 31, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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] to the facility.
Diagnoses included dementia with psychotic disturbance, delusions, hallucinations, and depression.
Record review of Resident #31's quarterly MDS dated [DATE], 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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
675599 12/31/2025
Robert Lee Care Center 307 West 8th St Robert Lee, TX 76945
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.
675599 12/31/2025
Robert Lee Care Center 307 West 8th St Robert Lee, TX 76945
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.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.