Wellspring SNF

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 the proper maintenance of medical records to include monitoring documentation in Point Click Care.  Monitor current health records, follow-up on incidents, issues with skilled residents and/or families, and meetings as needed. Develop and maintain a working relationship with professional providers of care to skilled residents.  Assist the direct care nursing staff with admissions, transfers, and the discharge of residents. Monitor and follow-up with falls, infection control, skin issues, unusual occurrences, medication delivery error and any other issues as indicated by the DON.  Maintenance of quality assurance parameters including chart audits, log audits and the scheduling of in-services as indicated. Oversee the daily completion and adherence to documentation as required in PCC. Complete audits as per direction of the DON. Assist the direct care staff with admissions, transfers & discharges. Provide direct care nursing and supervisor responsibilities as indicted. Provide staff in-service and education as indicated. Communicate, clarify and obtain orders, and updates on resident condition, etc. with other Health Care Providers.

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. Respond promptly to emergencies and after hours calls. Maintain knowledge of all property emergency, safety, and disaster plans/procedures. Maintain office, shop, and storage and ensure that mechanical areas of the community are in accordance with SLC policies. Drive residents to stores or on special trips as needed. 

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. 

Responsible for medication supervision/administration 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 of Nursing. May be responsible for discharges, assessments, and clinical documentation as indicated.  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. Maintain confidentiality of residents’ and prospective residents’ information. Understand role in the Safety & Disaster Plan. Provide educational meetings for residents and staff.

Assist in planning and coordinating all resident activities.  Encourage residents to participate in programs and activities and provide transportation to them as needed. Lead various activities as directed by the Resident Programs Director. Order and maintain supplies for activities as needed.

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. 

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.

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. 

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