Health inspection·November 4, 2022

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide both a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (Form CMS-10055) and a Notice of Medicare Non-coverage (Form CMS-10123 general notice) for 2 of 3 residents (Residents #6 and #48) reviewed for Medicare Beneficiary Protection Notification when discharged from Medicare Part A Services with benefit days remaining. Residents Affected - Some 1. The facility failed to ensure Resident #6 was given a NOMNC (Form CMS-10123 general notice) and a SNF ABN (Form CMS-10055) when she was discharged from skilled services. 2. The facility failed to ensure Resident #48 was given a SNF ABN form in addition to the NOMNC when he was discharged from skilled services. These failures could place residents at risk of not being fully informed about services covered by Medicare. The findings include: Resident #6 Review of Resident #6's admission Record/Face Sheet, printed 11/04/22, revealed a [AGE] year-old female who was initially admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease, heart failure, and fibromyalgia. Review of the nursing notes, dated 8/13/22, revealed Resident #6 was transferred via ambulance to the hospital emergency room for evaluation due to confusion and hallucinations. Review of the nursing notes, dated 8/26/22, revealed Resident #6 returned from the hospital and was readmitted to the facility with diagnoses of congestive heart failure, hypertension, anxiety, depressive disorder, and status post pneumonia. Review of the nursing notes, dated 8/27/22, revealed Resident #6 required skilled nursing services, observation for medication management, and skilled rehabilitation services for physical therapy, occupational therapy, and speech therapy. Review of the beneficiary notification for Resident #6 revealed an Advanced Beneficiary Notice of Non-coverage (ABN Form CMS-R-131) had been provided and signed by the resident on 9/26/22. The form did not document when skilled Medicare services would end. Page 1 of 12 455957 455957 11/04/2022 Santa Fe Health & Rehabilitation Center 1205 Santa Fe Dr 1205 Santa Fe Dr, TX 76086

F 0582 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some [There was no documented evidence Resident #6 had been provided with a NOMNC (Form CMS-10123 general notice) specifying when skilled Medicare services would end.] Resident #48 Review of Resident #48's admission Record/Face Sheet, printed 11/04/22, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. The resident's documented diagnoses included cerebral infarction, hemiplegia and hemiparesis affecting the left side, hypertension, chronic obstructive pulmonary disease, sleep apnea, diabetes mellitus type 2, osteoarthritis, and other depressive disorders. Review of the nursing notes, dated 6/06/22, documented Resident #48 tested positive for COVID. The resident's physician was notified and a new order was received for Molnupiravir 800 mg by mouth every 12 hours for 5 days for COVID. The resident's daughter was notified and a message was left to return the call to the facility. Resident #48 was moved to the COVID unit. Review of the nursing notes, dated 6/07/22, documented Resident #48 required skilled nursing services and observation for respiratory [status] and skilled rehabilitation services. Review of the beneficiary notifications for Resident #48 revealed a NOMNC (Form CMS-10123 general notice) had been provided and documented skilled Medicare services would end on 7/15/22. The form was signed by Resident #48 on 7/14/22. An Advanced Beneficiary Notice of Non-coverage (ABN Form CMS-R-131) had been provided and signed by the resident on 7/24/22. The form did not document when skilled Medicare services would end. In an interview on 11/01/22 at 9:20 AM, the Case Mix Manager/MDS Coordinator stated she was responsible for completing the beneficiary notification forms. During an interview and record review on 11/04/22 at 2:19 PM, the Business Office Manager reviewed the records for Resident #6's and #48's Medicare Part A days. She stated both she and the CMM kept up with the residents' MCR A days. The Business Office Manager stated Resident #6 was admitted to the facility on [DATE] with Medicaid Hospice services and went to the acute care hospital on 8/13/22. She was discharged from hospice care services. Resident #6 returned to the facility on 8/26/22 and was readmitted with Medicare Part A skilled care services. The Business Office Manager stated Resident #6 used 38 days total, as she had used 2 days during October 2022. The Business Office Manager stated Resident #48 received Medicare Part A skilled services on 6/06/22 due to testing positive for COVID-19. She stated the resident received antibiotic therapy and required skilled observation for cardiac and respiratory medication management until 7/15/22. In an interview on 11/04/22 at 3:17 PM, the Regional Nurse Consultant stated she did not know why Form CMS-10055 SNF ABN had not been used by the CMM for Resident #6 and Resident #48. She stated she was not familiar with Form CMS-R-131 ABN. The Regional Nurse proceeded to make a telephone call to the Regional Reimbursement Consultant. Following her telephone conversation, she reported the Regional Reimbursement Consultant had stated he had trained the CMM on use of the wrong form. The Regional Nurse Consultant proceeded to make a telephone call to another Regional Reimbursement Consultant for the corporation who worked in the same area. Following her telephone conversation, she reported the other Regional Reimbursement Consultant had stated she used the Form CMS-10055 and Form CMS-10123. The Regional Nurse Consultant stated the Beneficiary Notice Guidelines document was what was used by the facility to determine which beneficiary notice form was to be used and provided to the 455957 Page 2 of 12 455957 11/04/2022 Santa Fe Health & Rehabilitation Center 1205 Santa Fe Dr 1205 Santa Fe Dr, TX 76086

F 0582 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some residents and/or residents' representatives when skilled Medicare services would end. She stated there was not any other policy or procedure. Review of the facility's Beneficiary Notice Guidelines document, dated 2020, revealed the Advanced Beneficiary Notice of Non-coverage (Form CMS-R-131) was used for residents who had received Medicare Part B services [not residents who had received skilled Medicare Part A services]. 455957 Page 3 of 12 455957 11/04/2022 Santa Fe Health & Rehabilitation Center 1205 Santa Fe Dr 1205 Santa Fe Dr, TX 76086

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review program (PASRR) to the maximum extent practicable to avoid duplicative testing and effort for 1 of 2 (Resident #38) reviewed for PASARR. Resident #38 with diagnoses of mental illness, did not receive a PASARR Level II screening. This failure could place residents at risk of not receiving needed care and services, causing a possible decline in mental health. Findings include: Record Review of Resident #38's Face Sheet, dated 11/03/22, revealed he was a [AGE] year-old male, initially admitted to the facility on [DATE], with the following diagnoses: anxiety disorder with an onset date of 02/14/20, post-traumatic stress disorder with an onset date of 02/14/20, bipolar disorder with an onset date of 03/10/20, and major depressive disorder with an onset date of 03/09/22. Record Review of the quarterly MDS assessment, dated 09/14/22, revealed Resident #38, (Section I Active Diagnoses), Psychiatric/Mood Disorder diagnosis had active diagnosis for anxiety disorder, depression, and manic depression (bipolar disorder) and post-traumatic stress disorder. Record Review of Resident #38's PASARR Level I Screening (PL1), dated 02/14/20, was positive for (MI) mental illness. A PASARR Level II Screening (PE), dated 02/18/20 was identified in the clinical record, however, there was no indication that Resident #38 had a PASARR Level II Screening (PE) after the diagnosis of major depressive disorder with an onset date of 03/09/22 was identified. In an interview, on 11/03/22 at 1:51 PM, the Regional Consultant said a 1012 form (a form that is used to determine whether the Resident has a primary dementia diagnosis or if the individual has a mental illness diagnosis) should have been completed when Resident #38 was diagnosed with major depressive disorder when it was identified on 03/09/22, but it was not. He said he was responsible at that time when Resident #38 was diagnosed, but it was missed. There was no facility policy regarding PASARR. 455957 Page 4 of 12 455957 11/04/2022 Santa Fe Health & Rehabilitation Center 1205 Santa Fe Dr 1205 Santa Fe Dr, TX 76086

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents and the residents' representatives were invited to participate and included with the interdisciplinary team in the development and review of comprehensive care plans for 9 of 20 residents (Resident #s 2, 38, 39, 43, 59, 67, 70, 76, and 79) whose records were reviewed for care plan conferences. 1. Resident #2 did not have a care plan prepared by the interdisciplinary team after completion admission of the MDS assessment dated [DATE]. 2. Resident #38 did not have a care plan prepared by the interdisciplinary team following completion of the Significant Change MDS assessment dated 9/14/ 22. 3. Resident #39 did not have a care plan prepared by the interdisciplinary team following completion of the Quarterly MDS assessment dated 9/14/ 22. 4. Resident #43 did not have a care plan prepared by the Interdisciplinary team following completion of the Quarterly MDS assessment dated [DATE]. 5. Resident #59 did not have a care plan completed by the interdisciplinary team following completion of the Quarterly MDS assessment dated [DATE]. 6. Resident #67 did not have a care plan completed by the interdisciplinary team following completion of the Quarterly MDS assessment dated [DATE]. 7. Resident #70 did not have a care plan prepared by the interdisciplinary team following completion of the Quarterly MDS assessment dated [DATE]. 8. Resident #76 did not have a care plan completed by the interdisciplinary team following completion of the Significant Change MDS assessment dated [DATE]. 9. Resident #79 did not have a care plan completed by the interdisciplinary team following completion of the Quarterly MDS assessment dated [DATE]. This failure placed residents at risk for not having input into their daily care and the services required to meet their individual needs. The findings included: Resident #2 Review of Resident #2's Face Sheet, dated 11/3/22, revealed a [AGE] year-old female with an admission date of 10/3/22. The form documented the resident's diagnoses included mild cognitive impairment, and chronic obstructive pulmonary disease. Record review of Resident 2's MDS history revealed an admission MDS was done on 10/7/22 and there was no documentation that the interdisciplinary team prepared the comprehensive care plan after 455957 Page 5 of 12 455957 11/04/2022 Santa Fe Health & Rehabilitation Center 1205 Santa Fe Dr 1205 Santa Fe Dr, TX 76086

F 0657 completion of this MDS . Level of Harm - Minimal harm or potential for actual harm In an interview with Resident #2 on 11/02/22 at 09:01 AM she stated she could not remember ever attending a care plan meeting. Residents Affected - Some In an interview with the MDS coordinator and the Regional Nursing consultant on 11/03/22 at 2:08 PM both stated there was no care plan meeting with the resident/ family invited held after reviewing the care plan history of resident #2. They stated the failure occurred when the previous social worker failed to send the care plan invitations Resident #39 Review of Resident #39's Face Sheet, dated 11/3/22, revealed a [AGE] year-old female with an admission date of 5/25/22. The form documented the resident's diagnoses included abnormal weight loss, hypertension, and type 2 diabetes. Record review of Resident 39's MDS history revealed a Significant change MDS was done on 8/31/22 and there was no documentation of an interdisciplinary care plan meeting occurring after completion of this MDS. In an interview with Resident #39 on 11/02/22 at 09:01 AM she stated she could not remember ever attending a care plan meeting. In an interview with the MDS coordinator and the Regional Nursing consultant on 11/03/22 at 2:08 PM both stated there was no care plan meeting held after reviewing the care plan history of resident #39. They stated the failure occurred when the previous social worker failed to send the care plan invitations Resident #38 Review of Resident #38's Face Sheet, dated 11/3/22, revealed a [AGE] year-old male with an admission date of 2/14/20. The form documented the resident's diagnoses included post-traumatic stress disorder, bipolar disorder, chronic deep vein thrombosis (blood clots), and aphasia (inability to speak). Record review of Resident 38's MDS history revealed a Significant change MDS was done on 9/14/22 and there was no documentation of an interdisciplinary care plan meeting occurring after completion of this MDS. Resident 38's significant change MDS revealed he had a BIMS score of 7 and which indicated moderate cognitive impairment . He was not interview-able. In an interview with the MDS coordinator and the Regional Nursing consultant on 11/03/22 at 2:08 PM both stated there was no care plan meeting held after reviewing the care plan history of Resident #38. They stated the social worker was responsible for inviting residents, their families, and members of the interdisciplinary team to care plan meetings and for scheduling the meetings. They stated the failure occurred when the previous social worker failed to send the care plan 455957 Page 6 of 12 455957 11/04/2022 Santa Fe Health & Rehabilitation Center 1205 Santa Fe Dr 1205 Santa Fe Dr, TX 76086

F 0657 invitations Level of Harm - Minimal harm or potential for actual harm Resident #43 Residents Affected - Some Review of Resident #43's Face Sheet, dated 11/3/22, revealed an [AGE] year-old male with a readmission date of 9/14/20. The form documented the resident's diagnoses included dementia, type 2 diabetes, hypertension, and obesity. Record review of Resident 43's MDS history revealed a Quarterly MDS was done on 9/20/22 and there was no documentation of an interdisciplinary care plan meeting occurring after completion of this MDS. Resident 43's Quarterly MDS revealed he had a BIMS score of 2 and which indicated severe cognitive impairment . He was not interview-able. In an interview with the MDS coordinator and the Regional Nursing consultant on 11/03/22 at 2:08 PM both stated there was no care plan meeting held after reviewing the care plan history of resident #43 they stated the Last care plan conference was held on 7/20/22. They stated the failure occurred when the previous social worker failed to send the care plan invitations Resident #59 Review of Resident #59's admission Face Sheet, dated 11/03/22, revealed an [AGE] year-old male initially admitted to the facility on [DATE]. The form documented the resident's diagnoses included hypertension, peripheral vascParkinsons Disease,and chronic lung diseaseular disease, Review of Resident #59's care plan history revealed a baseline care plan dated 12/03/21 and a comprehensive care plan dated as initiated 713/21. Review of Resident #59's MDS history revealed the most recent assessment completed was a Quarterly MDS, dated [DATE]. Review of Resident #59's care plan conference forms revealed the most recent care plan meeting was held on 7/13/21. Review of the care plan conference form, dated 6/29/22, revealed no evidence of the physician, dietary manager, or resident or resident family attending. There was no documented evidence a care plan conference/meeting had been held for Resident #59 following completion of the Quarterly MDS assessment dated [DATE]. In an interview on 11/3/22 at 4:24 PM, Resident #59 stated he didnot ever remember attending a care plan meeting. Resident #67 Review of Resident #67's admission Record/Face Sheet, dated 11/04/22, revealed an [AGE] year-old female initially admitted to the facility on [DATE]. The form documented the resident's diagnoses included stage 4 pressure ulcer of the sacral region, chronic kidney disease, essential hypertension, hypertensive heart disease, atrial fibrillation, peripheral vascular disease, atherosclerotic heart 455957 Page 7 of 12 455957 11/04/2022 Santa Fe Health & Rehabilitation Center 1205 Santa Fe Dr 1205 Santa Fe Dr, TX 76086

F 0657 disease, and unspecified dementia. The form listed the resident's daughter as her emergency contact. Level of Harm - Minimal harm or potential for actual harm Review of Resident #67's care plan history revealed a baseline care plan dated 12/03/21 and a comprehensive care plan dated as initiated 12/30/21. The comprehensive care plan was dated as reviewed and revised 6/24/22. Residents Affected - Some Review of Resident #67's MDS history revealed the most recent assessment completed was a Quarterly MDS, dated [DATE]. Review of Resident #67's care plan conference forms revealed the most recent care plan meeting was held on 6/29/22. Review of the care plan conference form, dated 6/29/22, revealed Resident #67 was invited and attended, the family/responsible party was invited and attended, and the facility staff participants were a nurse, the social worker, and the activity director. [There was no documented evidence a care plan conference/meeting had been held for Resident #67 following completion of the Quarterly MDS assessment dated [DATE].] In an interview on 11/02/22 at 4:24 PM, Resident #67 stated she had attended a care plan meeting, but the meetings were not held consistently. Resident #70 Review of Resident #70's admission Record/Face Sheet, dated 11/04/22, revealed a [AGE] year-old male admitted to the facility on [DATE]. The form documented the resident's diagnoses included unspecified dementia, cerebral infarction, hemiplegia, and hemiparesis affecting the right side, aphasia following nontraumatic intracerebral hemorrhage, dysphagia, gastro-esophageal reflux disease, and other recurrent depressive disorders. The form listed the resident's spouse as the first emergency contact. Review of Resident #70's MDS assessment history revealed an admission MDS was completed 7/06/22 and a Quarterly MDS assessment was completed 9/20/22. Review of Resident #70's care plan history revealed a baseline care plan dated 6/29/22 and a comprehensive care plan dated as initiated 7/11/22. Review of Resident #70's care plan conference forms revealed the most recent care plan meeting was held on 7/13/22. Review of the care plan conference form, dated 7/13/22, revealed Resident #70 was invited and attended, the family/responsible party was invited and did not attend, and the only facility staff participants were a nurse and the social worker. [There was no documented evidence a care plan conference/meeting had been held for Resident #70 following completion of the Quarterly MDS assessment dated [DATE].] Observation on 11/01/22 at 11:09 AM revealed Resident #70 was lying on his back in a low bed with an air mattress with bolster pads; a floor mat was at the bedside. Resident #70 made eye contact and appeared to hear and understand when spoken to, as he nodded or shook his head in response to questions. 455957 Page 8 of 12 455957 11/04/2022 Santa Fe Health & Rehabilitation Center 1205 Santa Fe Dr 1205 Santa Fe Dr, TX 76086

F 0657 Resident #76 Level of Harm - Minimal harm or potential for actual harm Review of Resident #76's Face Sheet, dated 11/3/22, revealed a [AGE] year-old male with an admission date of 10/3/22. Residents Affected - Some Review of the resident's History and physical dated 10/17/22 chronic lower extremity non healing wounds, osteomyelitis, and chronic urinary retention with aa foley catheter. Record review of Resident 76's MDS history revealed a significant change MDS 9/26/22 and there was no documentation of an interdisciplinary care plan meeting occurring after completion of this MDS. In an interview with Resident #76 on 11/02/22 at 10:52 AM Resident 76 stated he has never been invited to a care plan meeting. Record review of Resident 76's Care Plan Meeting history revealed the last care plan meeting was held on 2/23/2022. In an interview with the MDS coordinator and the Regional Nursing consultant on 11/03/22 at 2:15 PM both stated there was no care plan meeting with the resident/ family invited held after reviewing the care plan history of resident #2. They stated the failure occurred when the previous social worker failed to send the care plan invitations Resident #79 Review of Resident #79's Face Sheet, dated 11/3/22, revealed an [AGE] year-old male with an admission date of 10/3/22. Review of the resident 79's face sheet dated 10/17/22 revealed diagnoses of arteriosclerotic heart disease (hardening of the arteries), hypokalemia (low potassium), dementia and hypertension. Record review of Resident 79's MDS history revealed an admission MDS 9/26/22 and there was no documentation of an interdisciplinary care plan meeting occurring after completion of this MDS. Record Resident 79's Care Plan Meeting history revealed the last care plan meeting was held on 2/23/2022 In an interview with Resident #79's family member and power of attorney on 11/01/22 at 3:20 PM She stated she is not invited to care plans. She also stated she didn't know they ever did care plans here. Interview with MDS nurse and the social on 11/3/22 at 2:15 pm revealed the social worker is responsible for inviting residents to a care plan meeting. She stated the current social worker was hired approximately 10 days ago and the prior social worker quit in September. She confirmed that there was a base line care plan on Resident 79's chart dated 9/18/22 and there was no documentation of any care plan meetings held. She stated the social worker was not in the facility and not available for interview during the survey. 455957 Page 9 of 12 455957 11/04/2022 Santa Fe Health & Rehabilitation Center 1205 Santa Fe Dr 1205 Santa Fe Dr, TX 76086

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an interview on 11/3/22 at 10:20 AM the DON stated it was her expectation that the care plan would be developed by the IDT and the resident and/or responsible party would be invited to participate in the meeting. Review of the facility policy title: Care Planning - Interdisciplinary Team and CAAs (Care Area Assessments) dated, revised 5/16/16 revealed in part: Care Plan meetings will be conducted within 21 days of admission to the facility and at least quarterly thereafter. The meeting will be scheduled by the social worker . The social worker will send out invitation letters resident family members, responsible parties, as well as any other entity required to attend. The social worker will use the facilities designated form to for documentation of the IDT meeting. The form will be filed in the Residents chart 455957 Page 10 of 12 455957 11/04/2022 Santa Fe Health & Rehabilitation Center 1205 Santa Fe Dr 1205 Santa Fe Dr, TX 76086

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review the facility failed to distribute and serve food in accordance with professional standards for food service safety as evidenced by; one of one dietary aide observed using unsanitary practices while transferring drinking glasses and filling drinking glasses with ice as well as a catch tray in dining room that was worn and pitted and had a thick, black tarry appearing substance along the back above a wire rack that was also covered in some sort of viscous looking substance. Dishwashing machine also was not reaching minimum concentration for sanitizing rinse. These failures could place residents at risk of acquiring foodborne and other illnesses. Findings include: On 11/2/2022 at 10:28 AM observed ice and water dispenser in the facility dining area that had a tarry, black, viscous looking coating along the back portion of the catch tray. The catch tray itself was dark gray plastic that is pitted and has a dirty appearance. The metal grate in the catch tray was also dirty with an unidentified accumulation covering about two-thirds of the grate. The backsplash above the catch tray which was stainless steel has a muddy brown appearance. A few minutes later at 10:35 AM observed a resident in a wheelchair pull up to the ice dispenser side, filling a cup with ice while holding the catch tray with her free hand. 11/2/2022 at 10:35 AM in an interview with DM about ice and water machine who said it is cleaned often and because of the material and age the tray always looks like it did. She could not identify what the black substance on the tray was. 11/2/2022 at 10:52 AM observed DM run chemical test strips on dishwashing machine. Three attempts were made with the DM adjusting the sanitation level between the second and third attempt. At no point did the test show at least 50PPM of sanitation occurring which is the lower range of 50-100 PPM of chemical sanitation recommended by the manufacturer. Immediately after the last attempt the DM called the company who maintains the machine and placed a service call. The kitchen switched to disposable plates for food service for the evening meal until the dishwashing machine was running properly. 11/2/2022 at 11:07 AM observed DA1 placing her fingers and thumb inside of drinking glasses to transfer them from one tray to another. After moving the glasses, she filled each with soda. 11/2/2022 at 11:24 AM observed DA1 again placing fingers and thumb into resident drinking glasses prior to filling them. 11/2/2022 at 11:30 AM observed DA1 wearing gloves and grabbing ice with gloved hands taking ice from one hand to another to put into resident drinking glasses. At no time was a scoop or other utensil used to transfer ice from the bowl into the glasses. 11/2/2022 at 11:40 AM DA1 continues using gloved hands to transfer ice into resident drinking glasses. 11/2/2022 at 11:55 in an interview with DA1, when asked if it was appropriate to put fingers and thumb inside of residents drinking glasses DA1 said no it was not the way to do it. When asked about 455957 Page 11 of 12 455957 11/04/2022 Santa Fe Health & Rehabilitation Center 1205 Santa Fe Dr 1205 Santa Fe Dr, TX 76086

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many using gloved hands to directly transfer ice into resident drinking glasses she also said it was not the correct way to do it. 11/2/2022 at 2:15 PM in an interview with DM, DM said DA1 should not have put her fingers and thumb into resident drinking glasses and should handle the glasses from the side. DM also said DA1 should not have been transferring ice with her gloved hands. 11/2/2022 at 3:35 PM record review of a policy titled Food & Nutrition Services Policy and Procedure Manual, Disposable Glove use in Dietary Service, Origination Date: 11/2006, Review Date: 11/14/2017, Revision Date: 11/14/2017 states the following. Policy Dietary staff will maintain proper food safety practices through proper hand washing and disposable glove use as appropriate. Fundamental Information Dietary Staff should wear disposable gloves when: Gloves are not worn when handling clean dishes. When washing dishes, after handling dirty dishes and prior to handling clean dishes, the employee will remove gloves and wash hands. 455957 Page 12 of 12