• Clearly written medication orders with directions and parameters (if necessary); indication that staff is following those orders and parameters
• Medications taken as ordered, via initials indicated on the Medication Administration/Assistance Record (MAR)
• Medications not taken include date and time, reason for refusal, and subsequent follow-up (i.e., reporting to the nurse, another supervisor, and/or the prescriber)
• As-needed medications documented, with follow-up to ensure medication was effective or, if not, steps taken to advocate for the resident
• Sample resident assessments and negotiated service agreements reviewed to ensure:
• Resident’s abilities and preferences regarding medications are included, and match the medication services the resident receives;
• If family assistance with medications is allowed, there is a written plan and back-up plan available and complete following WAC 388-78A-2290;
• Residents on the EARC, EARC-SDC, and/or AL Medicaid contracts receive medication administration should they be assessed as needing this service

• STORAGE including following storage directions on the label; secure storage (locked med carts, locked medication storage rooms/areas); adherence to storage temperature expectations; no expired or discontinued medications; controlled substances double-locked; meds organized per route, and separated per resident. 
• DELIVERY METHODS including documentation, proper assistance/administration methods; alterations in medications as ordered; privacy honored; resident preferences taken into consideration, residents observed taking medications. Prescriber’s orders will be compared to the medications delivered to ensure correct medications offered following standards of medication delivery.
• PRESCRIPTIONS received and started timely
• RESIDENT RIGHTS HONORED including the right to refuse medications; honoring residents’ choices and preferences
• DISPOSAL including proper medication destruction (two staff for controlled substances); following best practices

1. Non-Compliance - the facility has failed to meet one or more federal health, safety, and/or quality regulations; AND
2. Serious Adverse Outcome or Likely Serious Adverse Outcome – must be present. As a result of the identified noncompliance, serious injury, serious harm, serious impairment, or death has occurred, is occurring, or is likely to occur to one or more identified residents at risk; AND
3. Need for Immediate Action – the noncompliance creates a need for immediate corrective action by the provider to prevent serious injury, serious harm, serious impairment, or death from occurring or recurring.

• Likelihood instead of potential – Core Appendix Q makes it clear that to cite immediate jeopardy in situations where residents have not already suffered serious injury, harm, impairment, or death, the nature and/or extent of the identified noncompliance creates a likelihood (reasonable expectation) that such harm will occur if not corrected, not simply the potential for that level of harm to occur.
• Culpability was removed – Because the regulatory definitions of immediate jeopardy do not require a finding of culpability, that requirement was removed and replaced with the key component of noncompliance.
• Psychosocial harm – Core Appendix Q includes a section instructing surveyors to consider whether noncompliance caused or made likely serious mental or psychosocial harm to residents. In situations where the psychosocial outcome to the resident may be difficult to determine or incongruent with what would be expected, the guidance instructs surveyors to use the reasonable person concept to make that determination. The reasonable person approach considers how a reasonable person in the resident’s position would be impacted by the noncompliance.
• No automatic immediate jeopardy citations – Core Appendix Q makes it clear that each immediate jeopardy citation must be decided independently and there are no automatic immediate jeopardy citations.