This regulation requires nursing facilities to develop menus that meet residents' nutritional needs in accordance with national guidelines, are prepared in advance and followed, reflect residents' religious, cultural, and ethnic preferences, are periodically updated, and are reviewed by a qualified dietitian or nutrition professional. Facilities must make reasonable efforts to accommodate individual resident preferences and dietary needs, including offering alternatives when primary menu items are not acceptable to a resident. Surveyors assess compliance through meal observations, interviews, and record reviews to determine whether menus and individual food plans are nutritionally adequate and preference-responsive.
View official sourceF803 (Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17) §483.60(c) Menus and nutritional adequacy. Menus must- §483.60(c)(1) Meet the nutritional needs of residents in accordance with established national guidelines; §483.60(c)(2) Be prepared in advance; §483.60(c)(3) Be followed; §483.60(c)(4) Reflect, based on a facility’s reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups; §483.60(c)(5) Be updated periodically; §483.60(c)(6) Be reviewed by the facility’s dietitian or other clinically qualified nutrition professional for nutritional adequacy; and §483.60(c)(7) Nothing in this paragraph should be construed to limit the resident’s right to make personal dietary choices. INTENT §483.60(c)(1)-(7) - To assure that menus are developed and prepared to meet resident choices including their nutritional, religious, cultural, and ethnic needs while using established national guidelines. DEFINITIONS §483.60(c)(1)-(7) “Reasonable effort” means assessing individual resident needs and preferences and demonstrating actions to meet those needs and preferences, including reviewing availability of procurement sources of such food items, identifying preparation methods and approaches, and determining whether purchasing and serving such items can occur. “Periodically” means that a facility should update its menus to accommodate their changing resident population or resident needs as determined by their facility assessment. See F838. This includes ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services. GUIDANCE §483.60(c)(1-7) The facility must make reasonable efforts to provide food that is appetizing to and culturally appropriate for residents. This means learning the resident’s needs and preferences and responding to them. For residents with dementia or other barriers or challenges to expressing their preferences, facility staff should document the steps taken to learn what those preferences are. It is not required that there be individualized menus for all residents; however, alternatives aligned with individual needs and preferences should be available if the primary menu or immediate selections for a particular meal are not to a resident’s liking. Facilities must make reasonable and good faith efforts to develop a menu based on resident requests and resident groups’ feedback. PROCEDURES §483.60(c)(1-7) If during meal observations, a resident’s dietary intake appears inadequate determine through interviews and record review if facility staff made reasonable efforts to review and/or adjust the menu and/or the individual resident’s food plan to meet the nutritional, religious, cultural, and ethnic needs, and preferences of the resident. If the survey team observes deviation from a resident’s planned menu, review documentation, i.e., diet card, medical record and interview the resident, food service manager or dietitian to support reason(s) for deviation from the planned menu. PROBES §483.60(c)(1-7) Through interviews, observations and record reviews determine if: • Residents are receiving food in the amount, type, consistency and frequency to maintain normal body weight and acceptable nutritional values. • Resident preferences and needs are incorporated into the development of the individual food plan? • A resident chooses not to consume certain foods or food groups such as the resident is a vegetarian or does not eat dairy, how does the facility ensure the resident’s menu and/or the individual resident’s food plan meets his or her nutritional needs? • Menus meet basic nutritional needs by providing meals based on individual nutritional assessment, the individualized plan of care, and established national guidelines and are periodically updated to mitigate the risk of menu fatigue? • Menus are reviewed and revised as needed by a qualified dietitian or other qualified nutrition professional? NOTE: Standard meal planning guides may be used for menu planning and food purchasing. They are not intended to meet the nutritional needs and preferences of residents and must be adjusted to consider individual differences. Some residents will need more due to age, size, gender, physical activity, and state of health. There are many guides , i.e., American Diabetes Association, Academy of Nutrition and Dietetics, American Medical Association, or U.S. Department of Agriculture, that are available and appropriate for use when adjusted to meet each resident’s needs. DEFICIENCY CATEGORIZATION • Examples of Level 4, immediate jeopardy to resident health and safety, include, but are not limited to: o The facility only maintains a one day supply of foods and drink on hand to prepare and serve their planned menus. This supply did not include foods to meet the nutritional needs or choices of residents. Several residents reported that they were often hungry and were told by staff that no snacks or other food was available. o Facility staff failed to follow a menu for a resident on a puree diet. The wrong texture of diet was provided which resulted in a choking incident for this resident. This placed the resident at risk for potential death or brain damage due to lack of oxygen from choking. • An example of Level 3, Actual harm (physical or psychological) that is not immediate jeopardy, includes, but is not limited to: o Based on a resident’s current comprehensive assessment, the resident’s nutritional needs changed; however facility staff did not change or updated a menu to meet the nutritional needs of this resident. As a result this resident experienced significant weight loss. • Examples of Level.2 - No actual harm with a potential for more than minimal harm (physical or psychological) that is not immediate jeopardy, include but are not limited to: o The facility failed to ensure the resident’s menus and/or the individual resident’s food plan met her/his nutritional needs and preferences. o A repetitive menu was provided to the residents resulting in complaints about the lack of variety in food options. • An example of Level 1 - No actual harm with a potential for minimal harm includes but is not limited to: o While no resident complaints were received during survey, it was observed that food items were being substituted with equally nutritious foods, but not noted or updated on the menu and residents were not notified of the change.