Gorham House

9a-630p Shift Provide direct and individualized nursing care to assigned residents based on established nursing protocol. Observe and assess for: pain/discomfort, oxygen therapy, all drainage, all dressings, and any incontinent elimination which may have occurred.  Provide ignition and ongoing systematic assessment of the physical, emotional, social, educational, and functional needs of the resident/family through observation, interview, and physical examination.  Interpret assessment data and information to assist in developing a plan of care.  Assure medical orders are transcribed and processed accurately and timely and integrate the medical care plan into the provision of nursing care. Assure that medication administration is correct, according to the established nursing policies and procedures. Provide accurate and timely documentation consistent with the resident plan of care.  Administer medication per physician orders. Document properly on MOR. Observe for any adverse reaction.  Assemble resident charts, resident records, and assure all necessary form are completed in a timely manner. Assure all monthly summaries are completed in a timely manner for assigned residents.  Prepare incident/accident reports for residents as needed per policy, notify AL Director, physician, and family post incident per policy and document accordingly.  Assist resident in learning self-care activities.  Supervise all resident assignments to nursing team members, and assure special instructions are given to team members.  Observe and supervise all meals to ensure residents receive the proper diet and any assistance required.  Monitor and organize all material resources necessary for meeting needs of assigned unit.  Recognize emergencies and life-threatening situations and initiate appropriate action. Ensure that resident call lights are promptly answered, and their needs are addressed timely and appropriately.  Assist with the orientation of new staff members.  Ensure that all scheduled activities take place on assigned unit by utilizing activity personnel and/or nursing personnel. 

This will be split role of floor CNA and Purchasing position.   Take and record vital signs. Measure and record height, weight, and fluid intake/output. Recognize abnormal changes in body functioning and importance of reporting such changes to a supervisor. Assist as needed with medication reminders, bathing, grooming, dressing, escort service, and other activities of daily living. Transfer, position, and turn residents. Provide skin care to residents. Contribute to the resident’s assessment and the plan of care. Provide nursing rehabilitation/restorative nursing services. Follow the schedule of resident’s needs set out by supervisor. Provide emotional and social support to residents. Promote and protect resident rights, assist residents in making informed decisions, treat residents with dignity and respect, protect resident’s personal belongings, report suspected abuse or neglect, avoid the need for physical restraints in accordance with the current professional standards, and support independent expression, choice, and decision-making consistent with applicable law and regulation. Inform supervisor of any resident issues or concerns. Respect and encourage the independence and dignity of the residents. Respect residents’ confidentiality. Ordering of medical supplies for the community

Greet residents and provide general assistance to visitors, prospective residents, and families. Answer telephone calls. You may be asked to ensure the safety of the residents and property by monitoring surveillance cameras, door alarms, life safety systems, building alarms and investigating any unusual activity. Process reports for such things as work orders, incidents and concerns. You will receive packages, plants, prescription drugs, etc. and deliver or hold as requested.  Maintain the sign in/out log for the issuance of community keys, and gate passes. You will assist other departments with administrative functions. Ensure that resident/family/employee concerns receive timely response and follow up, thus striving to provide a high level of customer satisfaction. Maintain a positive and professional demeanor toward all residents, visitors and co-workers.

As part of the admission process, meet with the resident and family to review policies on advanced directives, resident rights, and discrimination. Conduct and document a social services evaluation, including identification of Resident problems/needs. Provide/arrange for social work services as indicate by resident/family needs. Assist residents, as needed, with financial planning. Keep the resident’s family informed of resident problems, personal needs, transfers, and changes of level assignment. Maintain a current list of community resources to facilitate referrals. Working knowledge and ability to apply professional standards of social work practice in job situations. Able to establish criteria to assure that services provided meet established standards of quality. Demonstrate satisfactory level of interpersonal skills to interact with residents, families, community and interdisciplinary staff. Demonstrate assessment skills sufficient to evaluate residents’ behavior, to collect data to evaluate psycho- social needs, risk factors for psycho- social deterioration and residents’ responses to interventions. Able to interpret and explain resident behavior to staff in way that fosters understanding, facilitates treatment and respect for resident rights and minimizes use of chemical and physical restraints. Implement social service interventions that achieve treatment goals, address resident needs, link social supports, physical care and physical environment to enhance quality of life.

Serve as the key point person for labor management of a multi-level assisted and skilled nursing community. Create and maintain weekly schedules for clinical employees for both the assisted living and nursing home neighborhoods. Improve financial performance by improving efficiency, eliminating redundant work schedules, reducing agency utilization and maximizing in-house shift pick ups.  Handle scheduling conflicts and update team members about schedule changes.  Respect and maintain confidentiality of the office, its records and restricted information.  Responsible for creating and scheduling Nursing Assistants and Nurse’s of the Nursing Department.  Attend various community events.  Attend all required training, in-service, and staff meetings.  Strive to maintain a safe working environment through the prevention of accidents, the preservation of equipment, and the achievement of safe working practices.  Maintain a positive and professional demeanor toward residents, visitors, families, and co-workers.  Adhere to all policies and procedures of Senior Lifestyle Corporation.  Perform other duties as assigned. 

Maintain complete and accurate medical records in compliance with the rules and regulations of all regulatory agencies and the standards of excellence promoted by the American Medical Records Association. Maintain and keep current the Admittance Log Book. Assemble and complete all new charts with resident assigned medical records number, name, physical name, or any other information pertinent to the resident. Maintain resident charts according to Medical Records Procedure Manual to meet regulations and to ensure ease of handling, and reports deficiencies to Director of Nursing / Assistant Director of Nursing. Establish and maintain a chart alphabetical filing system for both current and discharged residents in the medical records office. Follow procedures established in Medical Records Procedure Manual for releasing resident information. Handle discharged residents’ charts as outlined in medical Records Procedures Manual; monitor for uncompleted records or notes; notify Director of Nursing, or appropriate department head, of any deficiencies. Enter all necessary information in the “Death Registry” when a resident expires.  Obtain a copy of the death certificate and file with the residents’ chart. Maintain master inventory list at par levels and current costs, updating as needed; monitor par levels with Nursing Unit Usage. Conduct daily inventory count of all supplies storage areas. Upon arrival of delivery of supplies, making sure quantities received, match packing slip. Maintain nursing supplies, place delivered supplies in appropriate storage area, and apply charge tickets. Review and code as needed all residents charges daily.  Forward charges to Business Office. Keep all supply storage areas neat and orderly.

Responsible for supervision of self-administered medication for the Memory Care Department in compliance with Federal & State regulations and Senior Lifestyle Corporation guidelines as directed by the LPN/LVN/RN and/or the Director of Health & Wellness. Count and sign on approved form, all narcotics with approved personnel before accepting medication keys.  Contact a supervisor immediately with discrepancies. Order all necessary medication and treatments from appropriate pharmacy or notify responsible party when supply is no less than 7 days. Notify supervisor when supply is less than 2 days and medicine hasn’t been received. Responsible for receiving and verifying all medicine received is accurate according to pharmacy label and MAR.  Notifies pharmacy and DH&W of any discrepancies. Responsible for proper storage of all medications and ensuring all lotions, ointments and liquids stored separately from oral medications. Responsible for dating all appropriate vials or bottles at time of initial opening and following pharmacy protocol on length of time they can be used. Responsible for weekly inspections of all medications to ensure all expired medications are removed. Responsible for verifying all current MARs are compared to new MARs at change over time and notifying the supervisor of any discrepancies. Responsible for removing all discontinued medication from med cart and giving it to the supervisor. Provide personal care to residents to include, but not limited to, bathing, skin care, oral hygiene, grooming, dressing, incontinence care, and eating, etc. Provide general nursing care to include, but not limited to, vital signs, temperatures, blood pressure, and weights. Document appropriate information in the daily log as required and notify supervisor of all concerns. Answer calls and assist residents with needs as assigned. Responsible for daily cleaning of all medicine carts at end of shift and restocking as needed.  Responsible for weekly deep cleaning of all med carts. Attend and participate in staff training and in-services. Must maintain accurate records to include preparation of all medical charts for new admissions and readmissions and ensures medical record is complete within forty-eight (48) hours as Policy and Procedure (P&P) and regulatory guidelines.

Responsible for medication administration for the residents in compliance with Federal & State regulations and Senior Lifestyle Corporation guidelines. May be responsible for the admissions of new residents to include all admission assessments and documentation. Responsible for completing acute and long-term care plans or service plans. May be responsible for clinical system tracking (i.e. wounds or infection control) under the direction of the director. Provide general consultation regarding health-related concerns within the community. Notify physicians and/or family members of any change in resident’s health and provides proper documentation. Respond quickly to all emergencies. Maintain close communication with all departments and staff members. Provide educational meetings for residents and staff. Understand roll in the Safety & Disaster Plan. Maintain confidentiality of residents’ and prospective residents’ information.     May be responsible for discharges, assessments, and clinical documentation as needed. 

Complete work orders around the community. Perform work and repairs needed to ready apartments prior to move-in’s. Order and organize maintenance supplies as needed.  Complete general maintenance projects, including installations and repairs involving plumbing, electrical equipment, carpentry, painting, equipment repair, snow removal, and landscaping.

Prepare all food using the daily planner and SLC standard recipes. Work the food line during mealtimes. Ensure that all food meets safety guidelines and that all kitchen areas meet sanitation guidelines. Ensure resident and guest satisfaction by responding quickly to needs and requests.  Maintain a positive and professional demeanor toward all residents, visitors and co-workers.