The violations affected all 153 residents who receive food from the facility's kitchen at 8781 Lakeview Avenue, according to inspection records from the Centers for Medicare and Medicaid Services.
Diet Aide 3 dipped sanitizer test strips into cleaning solution for just one second instead of the required 10 seconds, making it impossible to get an accurate reading of the sanitizer's strength. When observed a second time, the aide extended the testing time to three seconds — still far short of manufacturer guidelines.
Cook 2 told inspectors he needed to test sanitizer for 15 seconds, demonstrating widespread confusion among kitchen staff about basic food safety protocols.
"If food services workers did not follow manufacturer guideline's time length in dipping the test strip into Quat sanitizer, it could result in an inaccurate reading of the sanitizer concentration which could not ensure the effectiveness of the sanitizer," the facility's Registered Dietitian told inspectors. "Using ineffective Quat sanitizer could result to not properly sanitize food contact surfaces which could cause cross contamination and lead to food borne illness."
The sanitizer problems extended beyond testing. Multiple kitchen workers didn't know the proper concentration range for quaternary sanitizer, which should measure between 200-400 parts per million according to manufacturer guidelines posted above the sink.
Diet Aide 2 said the sanitizer should be 200-300 ppm, calling 400 ppm "too strong." Diet Aide 4 gave the same incorrect range. Diet Aide 3 said it should be "only 200 ppm." Cook 2 also said 200 ppm was correct and that "200-400 was not right concentration."
Seven diabetic residents on controlled carbohydrate diets received regular red Jello during lunch on March 17, with no labels distinguishing it from diet Jello. The residents' meal tickets clearly indicated they should receive diet versions.
"There could be a potential risk for residents with CCHO diet who consumed regular Jello could increase the resident's blood sugar level," the Registered Dietitian explained to inspectors.
Diet Aide 7, who was serving the Jello, told inspectors "she could not distinguish which Jello was diet and which Jello was regular without a label on the Jello."
The kitchen's problems weren't limited to improper food distribution. Seven residents on fortified diets — designed to add 300-400 extra calories daily for those who cannot maintain their weight — received vegetables without the required margarine during lunch.
The facility's fortified diet menu plan specifically called for "extra 1/2 oz melted margarine" on vegetables during lunch, but none of the observed residents received it.
Cook 1 confirmed to inspectors that fortified diet residents should receive margarine on vegetables during lunch. The Registered Dietitian explained that residents "who had an order for fortified diet did not get the extra calories per diet menu plan which could affect their nutritional status since there was no margarine on the vegetable."
Portion control failures compounded the nutritional problems. Cook 2 used a number 8 scoop instead of the required number 12 scoop when serving beef teriyaki for dinner, giving residents larger portions than planned. For salad, the Food and Nutrition Services Director used a 1/4 cup scoop instead of the required 1/2 cup scoop, serving half portions.
"Residents did not get the proper nutrition and the right amount serving size they were supposed to get per menu plan which could lead to nutritional deficit and could potentially result in weight loss," the Registered Dietitian told inspectors about the undersized salad portions.
Diet Aide 5 made cheese quesadillas by grabbing "two handful of shredded cheese from a plastic container without measuring," unable to locate the recipe or explain how much cheese she used.
Food temperature and texture problems plagued meal service. Nine residents complained to inspectors about cold, bland food. Resident 52 said served food is "warm not hot; cold food not cold; like ice cream sometimes is melty." Resident 146 said "The food sucks. Somedays food is warm and somedays its cold and bland."
A test meal conducted during dinner service found beef teriyaki at 111 degrees Fahrenheit, green beans at 100 degrees, and rice at 100 degrees — all below the facility's own 120-degree minimum standard for hot foods.
The Food and Nutrition Services Director acknowledged during the test that the pureed beef teriyaki "was not the right diet texture" with "beef fiber still intact." She said residents "could choke on it" and "could spit out the beef which could lead to decreased intake and cause weight loss."
All 13 residents on pureed diets received improperly textured meat during dinner on March 18. The facility's own policy states pureed food "should be of a smooth and moist consistency and able to hold its shape."
Two residents requiring nectar-thick liquids received improper consistencies. Resident 39 got lumpy milk with thickener sitting on the bottom of the cup and a regular shake instead of a thickened version. Licensed Vocational Nurse 6 told inspectors the resident "could aspirate if the resident consumed the regular shake."
Resident 85, also on nectar-thick liquids, received pudding-consistency milk and regular Jello. The nurse explained that Jello "would melt in her mouth and could become regular liquid which could cause coughing and aspiration."
Kitchen sanitation problems extended throughout the facility. Inspectors found dust on doorway frames, two staff members with uncovered facial hair, open food bags in the freezer, black grime buildup on refrigerator gaskets, and wilted vegetables in storage.
Eight boxes of English muffins expired in February remained in the dry storage pantry during the March inspection. Bags of ice sat on the lobby floor after someone accidentally turned off the ice machine overnight.
Staff training gaps were evident across multiple areas. Diet Aides 1 and 3 couldn't demonstrate proper meal cart cleaning procedures. Cook 2 and Diet Aide 2 didn't know how to calibrate food thermometers, with Cook 2 saying thermometers should be calibrated to 40 degrees Fahrenheit instead of the correct 32 degrees.
Diet Aides 3 and 4 didn't know how long to submerge washed kitchenware in sanitizer — the manufacturer guidelines posted above the sink clearly stated one minute, but Diet Aide 3 said 10 seconds and Diet Aide 4 couldn't answer at all.
The Registered Dietitian and Food and Nutrition Services Director admitted to inspectors they were "unsure how long washed kitchen ware needed to be submerged into the sanitizer."
Bedtime snacks proved insufficient for the facility's 153 residents. Five out of 10 residents at a council meeting said snacks weren't offered or adequate. Activity staff reported needing more snacks because residents wanted multiple items and they frequently ran out of fruit.
Resident 120, who is diabetic, told inspectors "the facility did not have sugar free or diabetic evening snacks available for her."
Activity Assistant 1 explained she collected snacks around 7 p.m. but "most of the residents wanted snacks and requested more than one snack." She said "there were not enough snacks to distribute, there fore no snacks were left available in the station counter for those residents who missed the time period when she offered the snacks."
The inspection found the facility lacked a comprehensive quality assurance plan to address these systemic problems across dietary services, despite federal requirements for ongoing quality improvement programs.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Riverside Postacute Care from 2025-03-21 including all violations, facility responses, and corrective action plans.