F0800

E

Cold, Unpalatable Oatmeal Served Repeatedly at Breakfast

Rockwall, Texas Survey Completed on 03-24-2026

Penalty

No penalty information released

Summary

The facility failed to provide a nourishing, palatable, well-balanced diet that met residents’ daily nutritional and special dietary needs and preferences, specifically related to the breakfast oatmeal served to multiple residents. Surveyors reviewed records for four residents and observed breakfast service on Hall 200. Resident #1, an elderly female with severe cognitive impairment and diagnoses including cerebral infarction, chronic respiratory failure, and atrial fibrillation, was observed eating oatmeal in bed; she stated she knew the oatmeal was cold and lumpy but was eating it because she was hungry. The oatmeal appeared sticky, and when the bowl was touched it was cold. Resident #1 later stated she did not mind cold food and would try to eat anything, but acknowledged the oatmeal would taste better if it were warm.

Resident #2, an elderly male with cerebral infarction, hypertension, and edema who was alert, oriented, and able to make decisions, was observed in the same room as Resident #1. He had eaten the rest of his breakfast but refused to eat the oatmeal, stating it was sticky, cold, lumpy, and looked disgusting, and that it was always served that way. He demonstrated that the oatmeal could be lifted from the bowl in one whole piece. Resident #3, an elderly male with COPD, heart failure, and congestive heart failure who was also alert and oriented, had finished his eggs and toast but had not touched his oatmeal. He stated he could not eat the oatmeal because it was terrible, always thick and cold, and showed that the entire bowl of oatmeal came out in one piece when he tried to stir it. He reported that he had told staff about the problem but nothing had changed.

Resident #4, an elderly female with cerebral infarction, hypertension, and muscle weakness who was alert and oriented, stated during breakfast that she would like her oatmeal to be warm and edible. She reported that the oatmeal was always served cold, sticky, and in one big lump, so she asked for extra toast instead, and said she had told CNAs but did not like to make a fuss. CNA A confirmed during interview that the oatmeal was always served lumpy and cold, that many residents complained, and that although she had informed the kitchen, nothing had changed. CNA A stated she tried to mix the cold oatmeal with warm eggs for Resident #1 and that residents declined offers of fresh oatmeal because they believed it would be the same. The Dietary Manager stated the oatmeal left the kitchen warm and she did not know what happened afterward, and reported no recollection of grievances about cold, inedible oatmeal. The Administrator and DON stated they were unaware of any problems with the oatmeal. The facility’s Dietary Services Meal and Food policy stated that food prepared for residents is to be prepared according to all applicable food service regulations.