Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Robert Lee Care Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and behavioral symptoms, including wandering and rejection of care, did not have these issues addressed in their care plan. Despite documentation of these behaviors and acknowledgment by the DON and MDS coordinator that they should have been care planned, the facility failed to include appropriate goals or interventions, contrary to its own care planning policy.
A resident with Parkinson's Disease and severe cognitive impairment, requiring substantial assistance with transfers, was not safely transferred by staff who used improper techniques such as lifting by the arm and holding by the waistband, contrary to facility policy and best practices. Therapy staff and the DON confirmed these methods were unsafe, and similar improper techniques were observed during a transfer demonstration on the DON.
Nurse aides failed to demonstrate competency in safe transfer techniques, as observed during transfers involving a resident with Parkinson's Disease and during a demonstration with the DON. Aides used improper methods such as lifting under the arm and holding the waistband, which did not align with facility policy or recommended practices. Staff interviews revealed inconsistencies in training and understanding of safe transfer procedures, and ongoing monitoring of transfer techniques was lacking.
The facility's kitchen failed to meet food safety standards, with improper storage and handling practices observed. Bowls were stored face up, food items were placed on the floor, and meat was improperly stored over other foods. Staff were seen practicing poor hygiene, such as turning off faucets with bare hands and handling clean dishes against their bodies. The Dietary Manager acknowledged these issues, indicating previous discussions with staff about proper practices.
A resident with paralysis following a stroke did not have a care plan addressing the use of her ankle splint, despite its presence at her bedside. The facility's policies require comprehensive care plans, but the MDS Coordinator and DON failed to include the splint in the resident's plan, risking inadequate individualized care.
A facility failed to assess, obtain orders, or monitor a resident's ankle splint, which was used to prevent drop foot following a stroke. The splint was not included in the resident's care plan or MDS assessment, and there was no order for its use. The DON and MDS Coordinator were unaware of the splint's inclusion in the care plan, and the necessary orders were not initiated, leading to the deficiency.
A facility failed to ensure proper oxygen safety signage for a resident requiring oxygen therapy. The resident, with COPD and heart failure, was moved to a new room without the 'No smoking oxygen in use' sign being transferred. The oversight was due to a lapse in communication and responsibility between the medical records staff and floor staff, contrary to the facility's policy on oxygen administration.
A facility failed to maintain an effective infection prevention and control program when the DON did not use Enhanced Barrier Precautions (EBP) during wound care for a resident with a laceration and abscess. The DON misunderstood the facility's policy, believing EBP was unnecessary for non-chronic wounds, leading to a risk of cross-contamination and infection.
The facility failed to post complete daily staffing information, including the facility name, total number and actual hours worked by RNs, LPNs, CNAs, and the resident census for two days. The postings, located behind the nurses' station, only listed the number of staff by title without further details. The DON and Administrator were unaware of the requirement to include hours worked, facility name, and census, despite the facility's policy mandating such information.
A resident with schizoaffective disorder and mild intellectual abilities was incorrectly coded as not PASRR positive on their MDS assessment, despite being PASRR positive since admission. The error was attributed to human oversight, as confirmed by the MDS coordinator, DON, and Administrator. The facility lacked a specific policy for MDS assessments, relying instead on the RAI manual instructions.
Failure to Develop and Implement Comprehensive Care Plan for Resident with Behavioral Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with significant behavioral and cognitive needs. Record reviews showed that the resident had diagnoses including dementia with psychotic disturbance, delusions, hallucinations, and depression, and was assessed with a BIMS score of 2, indicating severe cognitive impairment. The resident also exhibited behaviors such as wandering and rejection of care, as documented in the MDS. However, the care plan dated 4/16/2025 did not include any focus, goals, or interventions addressing these behaviors. Interviews with the DON and MDS coordinator confirmed that these behaviors should have been included in the care plan to ensure appropriate care and staff awareness. Both acknowledged that the omission was a failure to follow the facility's care planning policy, which requires the IDT to develop and implement a comprehensive, person-centered care plan describing the services needed to attain or maintain the resident's highest practicable well-being. The lack of a care plan for the resident's wandering and rejection of care was directly attributed to the MDS department not ensuring these needs were addressed.
Failure to Ensure Safe Transfer Techniques and Adequate Supervision
Penalty
Summary
The facility failed to ensure that residents received adequate supervision and assistance devices to prevent accidents during transfers. Specifically, one resident with Parkinson's Disease, muscle weakness, unsteadiness, and severe cognitive impairment required substantial to maximum assistance with transfers and used a wheelchair. During an observed transfer, two aides assisted the resident using a gait belt, but one aide placed her arm under the resident's arm and the other held the resident by the waistband of his pants, both of which are not safe transfer techniques. The aides believed they were following their training, although one acknowledged that lifting by the arm felt tight and uncomfortable. Interviews with therapy staff indicated that the correct method for a two-person gait-belt transfer involves one staff member in front and one behind, controlling the transfer from the resident's hips, and specifically avoiding lifting or pulling by the arms or waistband. The physical therapy assistant and physical therapist both stated that hooking under the arms or grabbing the waistband could cause discomfort or injury, and that these methods did not provide adequate control during transfers. The therapy department did not provide specific transfer training to aides but communicated the required level of assistance for each resident. Further observation of a transfer demonstration by two other aides on the Director of Nursing revealed that they also used improper technique by holding the forearms during the transfer. The Director of Nursing confirmed that staff were trained not to pull or tug on residents' arms and acknowledged that such actions could cause skin tears, bruising, or discomfort. The facility's policy emphasized the use of appropriate techniques and devices for safe lifting and movement of residents, but the observed practices did not align with these standards.
Failure to Ensure Competency in Safe Resident Transfers
Penalty
Summary
Nurse aides at the facility failed to demonstrate competency in safe transfer techniques for residents requiring assistance, as evidenced by observations and interviews. In one instance, two aides assisted a male resident with Parkinson's Disease, muscle weakness, and severe cognitive impairment in transferring from a recliner to a wheelchair. During the transfer, one aide placed her arm under the resident's arm while the other held the resident's pants by the waistband, contrary to safe transfer protocols. Both aides believed their methods were correct, though one acknowledged that being lifted by the arm could feel tight and uncomfortable. The resident's care plan indicated the need for substantial to maximum assistance with transfers, and the use of a gait belt was observed, but the techniques used did not align with best practices as described by therapy staff. Further review included a demonstration by two other aides who performed a two-person gait-belt transfer on the Director of Nursing (DON). During this demonstration, both aides held the gait belt in the back and assisted the DON to stand by holding the forearm, also deviating from recommended techniques. The DON confirmed that aides were instructed not to pull or tug on residents' arms and acknowledged that improper techniques, such as hooking under the arm or grabbing the waistband, could cause discomfort, skin tears, or bruising. The DON stated that staff were trained on transfers and that a skills fair was conducted for competency checks, but ongoing monitoring of transfer techniques was not performed. Interviews with therapy staff indicated that aides were not specifically trained by therapy on transfer techniques, though they were informed about the level of assistance required for each resident. The facility's policy emphasized the use of appropriate techniques and devices to ensure resident safety and comfort during transfers. However, the observed practices and staff interviews revealed inconsistencies between training, policy, and actual transfer methods used by aides, resulting in a failure to ensure staff competency in safe resident transfers.
Food Safety and Hygiene Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its kitchen, as observed during a survey. Specific deficiencies included improper storage and handling of food and dishes, which could lead to contamination. Observations revealed that bowls were stored face up, a bucket of pickles was placed on the ground in the walk-in refrigerator, and meat was stored over vegetables and bread in the freezer. Additionally, individual servings of jelly and packets of sugar were found on the floor in the dry storage area. A brisket was observed thawing over pickles, eggs, and bacon in the refrigerator, which poses a risk of cross-contamination. During meal preparation, staff members were observed engaging in improper hygiene practices. One cook was seen turning off the faucet with bare hands after washing, and a dietary aide transported clean dishes by holding them against her body, risking contamination. Another aide handled salad bar containers with bare hands, touching the food surfaces, and failed to wash hands after returning to the kitchen before donning gloves and continuing food preparation. Interviews with the Dietary Manager confirmed awareness of these issues, acknowledging previous discussions with staff about proper practices and the need for dishes to be stored face down and food to be kept off the floor.
Failure to Include Ankle Splint in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who had suffered a stroke and was admitted with paralysis affecting her dominant side. The resident, who was cognitively intact, had range of motion impairments and used a walker and wheelchair. Despite these needs, the care plan did not address the use of an ankle splint, which was observed at the resident's bedside. The absence of a care plan for the splint was confirmed through interviews with the MDS Coordinator and the Director of Nursing (DON), who acknowledged the oversight. The facility's policies on care planning and resident mobility emphasize the need for comprehensive assessments and individualized care plans developed by an interdisciplinary team. However, the resident's care plan lacked specific interventions related to the splint, which was intended to prevent drop foot. The MDS Coordinator was unaware of the splint, and the DON admitted that the resident had been using it since admission but had not included it in the care plan. This oversight placed the resident at risk of not receiving the necessary individualized care to meet her needs.
Failure to Monitor and Document Ankle Splint Use
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, the facility did not assess, obtain orders, or monitor the resident's ankle splint. The resident, who was admitted following a stroke that resulted in paralysis on her dominant side, had an ankle splint to prevent drop foot. However, the splint was not included in her care plan or MDS assessment, and there was no order for its use. Interviews revealed that the Director of Nursing (DON) and the MDS Coordinator were unaware of the splint's inclusion in the care plan or MDS. The DON acknowledged that the resident came in with the brace and that the staff were aware of it, but therapy did not initiate an order for the splint. The DON also mentioned that the therapist who initially worked with the resident and was aware of the splint no longer worked at the facility. Despite the nurses being educated on the splint's use and skin integrity checks, the necessary orders were not initiated, leading to the deficiency.
Failure to Ensure Oxygen Safety Signage
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident who required oxygen management, as observed during a survey. Specifically, the facility did not place a 'No smoking oxygen in use' sign on the doorway of the resident's room, which is a safety measure to inform anyone entering the room that oxygen is in use. This oversight was noted for a resident who had been admitted with chronic obstructive pulmonary disease (COPD), heart failure, and a dependence on supplemental oxygen. The resident was cognitively intact and had an order for oxygen administration at 2-5 liters per nasal cannula. The deficiency was identified when it was observed that the required signage was not present on the resident's door after the resident had been moved to a new room. Interviews with the Director of Nursing (DON) and the Medical Records staff revealed that the responsibility for ensuring the presence of the sign fell to the medical records staff, who were unaware that the sign had not been moved with the resident. The facility's policy on oxygen administration, revised in October 2010, clearly stated the need for such signage, yet this procedure was not followed, potentially placing the resident at risk.
Inadequate Infection Control Practices During Wound Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of the Director of Nursing (DON) during wound care for a resident. The resident, a male admitted to the facility with a laceration and abscess on the left arm, had a care plan that included wound care and antibiotic treatment following a hospital stay for sepsis. During an observation, the DON did not wear any Enhanced Barrier Precautions (EBP) personal protective equipment while providing wound care to the resident, which is contrary to the facility's policy. The DON, who also serves as the infection preventionist, stated that she believed EBP was not necessary for the resident's wound because it was not chronic. This misunderstanding of the facility's policy, which requires EBP for high-contact resident care activities regardless of the chronicity of the wound, led to a failure in infection control practices. The facility's policy specifies that EBP should be used to reduce the transmission of multidrug-resistant organisms, and the DON's actions placed residents at risk for cross-contamination and infection.
Failure to Post Complete Daily Staffing Information
Penalty
Summary
The facility failed to post daily staffing information that included the facility name, total number and actual hours worked by registered nurses, licensed practical or licensed vocational nurses, certified nurse aides directly responsible for resident care per shift, and the resident census for two days. This deficiency was observed during a survey conducted over three days, specifically on 09/25/2024 and 09/26/2024. The daily nursing posting, located behind the nurses' station, did not indicate the actual hours worked for each direct care staff, the facility name, the total number of staff, and the resident census. The posting only listed the number of staff by title, such as CMA, CNA, LVN, RN, and Admin, without further details. During an interview, the Director of Nursing (DON) and the Administrator acknowledged that the postings behind each nurse's station were intended to serve as the daily staffing post. However, they were unaware that the posting needed to include the number of hours worked, the facility name, and the census. A review of the facility's policy on nurse staffing posting information, dated August 2024, indicated that the facility should ensure staffing information is readily available in a readable format to residents and visitors at any given time. The policy specified that the nurse staffing sheet should be posted daily and contain the facility name, current date, facility's current census, and the total number and actual hours worked by various categories of licensed and unlicensed nursing staff directly responsible for resident care per shift.
Inaccurate PASRR Coding on MDS Assessment
Penalty
Summary
The facility failed to ensure an accurate assessment of a resident's status, specifically regarding the Preadmission Screening and Resident Review (PASRR) process. The deficiency involved a resident who was admitted with diagnoses including schizoaffective disorder and mild intellectual abilities. The resident's PASRR Level 1 screening indicated the presence of mental illness, intellectual disability, and a developmental disability. However, the resident's Minimum Data Set (MDS) assessment was incorrectly coded as not being PASRR positive, despite the resident being PASRR positive since admission. Interviews with the MDS coordinator, Director of Nursing (DON), and the Administrator revealed that the error was due to human oversight. The MDS coordinator acknowledged the mistake, stating that the resident should have been coded as PASRR positive. The DON and Administrator were also made aware of the error and confirmed it was a result of human error. The facility did not have a specific policy for MDS assessments and relied on the Resident Assessment Instrument (RAI) manual instructions.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Robert Lee
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bronte Health And Rehab Center | 11.8 mi | — | 11 | 0 |
| Sterling Nursing And Rehab | 29 mi | — | 8 | 0 |
| Cedar Manor Nursing And Rehabilitation Center | 29.2 mi | — | 5 | 0 |
| Sagecrest Alzheimers Care Center | 29.3 mi | — | 0 | 0 |
| Park Plaza Nursing And Rehabilitation Center | 29.3 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.