Inspection·December 31, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #3) reviewed for transfers in that: NA A and CNA B failed to safely transfer Resident #3 with a gait belt. CNA C and CNA D failed to demonstrate the skills to safely transfer the DON. These failures could place residents at risk for injuries due to not receiving the appropriate level of assistance to prevent accidents.Findings included: Review of Resident #3's admission Record, dated 12/30/25 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included Parkinson's Disease (a neurological disorder causing movement and cognitive impairment), muscle weakness, and unsteadiness on feet. Resident #3 was on hospice. Review of Resident #3's admission MDS Assessment, dated 11/25/25, revealed:Resident #3 had a BIMS score of 3 of 15 (indicating severe cognitive impairment). He showed signs of delirium including inattention and disorganized thinking that fluctuated.Resident #3 had upper and lower range of motion impairment on both sides.Resident #3 used a wheelchair.Resident #3 needed substantial to maximum assistance with transfers. Review of Resident #3's Care Plan revealed:Initiated 11/28/25: Focus: Resident had an ADL self-care performance deficit related to activity intolerance, and Parkinson's Disease. Goal: Declines will be addressed promptly. Identified interventions included: Transfer with one assist. Initiated 11/28/25 Focus: The resident has Parkinson's. Goal: Discomfort or complications related to Parkinson's disease through review date will be addressed promptly. Identified interventions included: encourage daily exercise, mobility as tolerated. Observation on 12/30/2025 at 10:42 AM revealed Resident #3 was in the recliner, CNA B put a gait belt on Resident #3. NA A and CNA B locked the wheelchair and helped Resident #3 slide forward to the edge of the recliner. NA A held the gait belt in the back and slid her arm under Resident #3's arm. CNA B held the front of the gait belt and held Resident #3's pants by the waistband. The aides assisted Resident #3 in standing and pivoting to the wheelchair. Interview on 12/30/2025 at 11:14 AM NA A stated she was a new aide and received training on transfers prior to working the floor. NA A stated she was trained to make sure the gait belt was on, the wheels were locked, the resident had non-slip footwear on, and make sure the resident's knees touched the sitting surface prior to the resident sitting down. NA A said she thought the transfer went pretty well and they completed the transfer how they were shown. NA A said she might be wrong in putting her arm under Resident #3's arm. NA A said she thought being lifted by the arm felt tight and pressured and was not comfortable. Interview on 12/30/2025 at 11:43 AM CNA B said she worked at the facility for 4 years. CNA B said she received training in how to do a two-person gait-belt transfer. CNA B stated she was trained to have each aide stand on either side of the resident, put on the gait belt, make sure the resident was ready, that the resident had a good foot surface, then help them stand, pivot and sit down. CNA B said she was trained that an arm went under the resident's arm when assisting the resident to stand. CNA B stated she thought she did that and was confident in how she did. CNA B said pulling up a resident by the seat of the pants could cause a skin tear and could be uncomfortable. Interview on 12/31/2025 at 9:50 AM the PTA E stated she was at the facility for over two years. PTA E stated Resident #3 was receiving therapy services and they worked on standing and safety awareness. PTA E stated the level of assistance Resident #3 needed fluctuated from a one person to a two-person transfer. PTA E stated for two-person assistance, the staff needed to put a gait belt on, one staff stand in front of the resident while the other stood behind guiding the resident to the wheelchair. PTA E stated hooking under a resident's arm was not supposed to be done during transfers. PTA E said she was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675599 If continuation sheet Page 2 of 5 Printed: 05/15/2026 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 675599 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: 675599 If continuation sheet Page 3 of 5 Printed: 05/15/2026 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 675599 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 Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs for 1 (Resident #3) of 4 residents reviewed for competent nursing staff, in that: NA A and CNA B failed to safely transfer Resident #3 with a gait belt. CNA C and CNA D failed to demonstrate the skills to safely transfer the DON using a gait belt. These failures could place residents at risk for injuries due to not receiving the appropriate level of assistance to prevent accidents.Findings included: Review of Resident #3's admission Record, dated 12/30/25 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included Parkinson's Disease (a neurological disorder causing movement and cognitive impairment), muscle weakness, and unsteadiness on feet. Resident #3 was on hospice. Review of Resident #3's admission MDS Assessment, dated 11/25/25, revealed:Resident #3 had a BIMS score of 3 of 15 (indicating severe cognitive impairment). He showed signs of delirium including inattention and disorganized thinking that fluctuated.Resident #3 had upper and lower range of motion impairment on both sides.Resident #3 used a wheelchair.Resident #3 needed substantial to maximum assistance with transfers. Review of Resident #3's Care Plan revealed:Initiated 11/28/25: Focus: Resident had an ADL self-care performance deficit related to activity intolerance, and Parkinson's Disease. Goal: Declines will be addressed promptly. Identified interventions included: Transfer with one assist. Initiated 11/28/25 Focus: The resident has Parkinson's. Goal: Discomfort or complications related to Parkinson's disease through review date will be addressed promptly. Identified interventions included: encourage daily exercise, mobility as tolerated. Observation on 12/30/2025 at 10:42 AM revealed Resident #3 was in the recliner, CNA B put a gait belt on Resident #3. NA A and CNA B locked the wheelchair and helped Resident #3 slide forward to the edge of the recliner. NA A held the gait belt in the back and slid her arm under Resident #3's arm. CNA B held the front of the gait belt and held Resident #3's pants by the waistband. The aides assisted Resident #3 in standing and pivoting to the wheelchair. Interview on 12/30/2025 at 11:14 AM NA A stated she was a new aide and received training on transfers prior to working the floor. NA A stated she was trained to make sure the gait belt was on, the wheels were locked, the resident had non-slip footwear on, and make sure the resident's knees touched the sitting surface prior to the resident sitting down. NA A said she thought the transfer went pretty well and they completed the transfer how they were shown. NA A said she might be wrong in putting her arm under Resident #3's arm. NA A said she thought being lifted by the arm felt tight and pressured and was not comfortable. Interview on 12/30/2025 at 11:43 AM CNA B said she worked at the facility for 4 years. CNA B said she received training in how to do a two-person gait-belt transfer. CNA B stated she was trained to have each aide stand on either side of the resident, put on the gait belt, make sure the resident was ready, that the resident had a good foot surface, then help them stand, pivot and sit down. CNA B said she was trained that an arm went under the resident's arm when assisting the resident to stand. CNA B stated she thought she did that and was confident in how she did. CNA B said pulling up a resident by the seat of the pants could cause a skin tear and could be uncomfortable. Interview on 12/31/2025 at 9:50 AM the PTA E stated she was at the facility for over two years. PTA E stated Resident #3 was receiving therapy services and they worked on standing and safety awareness. PTA E stated the level of assistance Resident #3 needed fluctuated from a one person to a two-person transfer. PTA E stated for two-person assistance, the staff needed to put a gait belt on, one staff stand in front of the resident while the other stood behind guiding the resident to the wheelchair. PTA E stated hooking (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675599 If continuation sheet Page 4 of 5 Printed: 05/15/2026 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 675599 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: 675599 If continuation sheet Page 5 of 5