JOB SUMMARY: Responsible for resident care and assessment within the training and scope of service for the residents directly assigned within the unit working; and coordinates care and treatment of each resident to provide resident

centered care.

Follows established policies and procedures of the facility and standards of practice associated with one's state license; provides residents with quality care; checks rooms routinely to insure residents are provided the care expected and ordered; ensures unit is adequately supplied and organized for efficient and effective resident care; provides resident and family education and information regarding their care and treatment.

Additionally, performs general nursing duties in all areas of the facility with adequate supervision; participates in Quality Assessment Performance Improvement plan of the organization; demonstrates the knowledge and skills necessary to provide care appropriate to the age of the residents served; must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the resident's status and interpret the appropriate information needed to identify each resident's requirements relative to his or her age-specific needs, and provide the care needed as described in the facility policies and procedures.

WORKING CONDITIONS: Works in well-lighted, well-ventilated rooms and halls. Sits, stands, bends, stoops and walks intermittently during the work day. May adjust and move residents and equipment. Subject to burns from equipment falls, bruises, scratches, etc., from residents and may be exposed to infections and odors. Must handle emergencies, give emergency care and give emergency instructions and deal with public, visitors, and residents tact fully.

ESSENTIAL FUNCTIONS AND DUTIES:

1. Conducts chart reviews to check staff's work and documentation for

accuracy and completeness. Discuss incomplete work with staff upon finding work not done. If incomplete work continues after discussions of incomplete work of more than 3 different occasions, then communicate with DON.

2. Make daily rounds on residents. Observations to include: Follow-up with

family issues, Medication Administration issues, Physician visits/outstanding orders, etc.

3. Prepares and administers medications, as ordered by the Physician.

4. Utilizes LTC consistently and accurately and serves as a resource person

for staff

5. Ensures an admission note is written on all new admissions - Ensures

care plan and care guide are established in LTC

6. Assist with entering Physician Orders in LTC.

7. Ensures clinical staff completes orientation materials and required

education and training expected by Facility policies and procedures.

8. Works with staff to ensure Call Lights are answered within 5 minutes.

9. Assist with feeding residents in dining room or resident room.

10. Ensures daily skill notes are completed correctly and quarterly

assessments timely

11. Assist in Care Plan meetings when ask.

12. Administer professional services such as; catheterization, tube feedings,

suction, applying and changing dressings/bandages, packs, colostomy and drainage bags, taking blood, and care POST Mortem & Palliative care, as required.

13. Review resident care plans for appropriate resident goals, problems,

approaches and revisions based on nursing needs.

14. Handles all problems and employees in a professional, consistent and fair

manner.

15. Maintains correct and professional communications with the public,

residents, employees and other agencies, reflecting the mission of Quality Rehab and Health Care.

16.Ensures adequate staffing is available.

17. Ensures Incidents or medication error reports are completed before end of

shift correctly with all information on checklist. Completes the section of investigation.

18. Reviews 24 hours Nursing Report for accuracy and completeness:

a. New orders b. Changes in resident conditions C. Behavior changes d. New Admissions & Discharges e. Suspected or confirmed Infections

19. Charts notes in LTC in an informative and descriptive manner that reflects

the care provided to the resident, as well as the resident's response to care.

20. Take and records TPR's and blood pressures, as necessary and records

in LTC.

21. Ensures that assigned work areas are maintained in a clean, safe and

sanitary manner. Monitors CNA's to ensure that they practice Universal Precautions and safety regulations in the use of equipment and supplies.

22. Interacts with co-workers, physicians, residents and all other customers in

a manner which encourages harmonious working relationships, enhances the image and reputation of the facility and promotes positive customer relations

23. Transcribes physician orders in a timely and accurate manner, and in

accordance with Woodcrest policies and procedures

24. Provides a brief written report to DON of any chart reviews for

documentation and assessments, family or resident issues, employee issues, medication observations, any LTC issues, and etc. at end of each shift worked.

25. Make periodic checks to ensure that prescribed treatments are being

properly administered by certified nursing assistants and to evaluate the resident's physical and emotional status.

26. Supports the facility and nursing's mission statement by dependability in

attendance, punctuality, maintaining confidentiality, the timely completion of assignments, and attention to principles of professional ethics and person-centered care.

27. Ensures the rights, dignity and confidentiality of all residents is maintained.

28. Responses promptly to requests from the Director of Nursing within the

requested timeframe

29. Implements changes as expeditiously as possible, and monitors staff to

ensure that the changes are being properly implemented

30. Has a commitment to professional and personal growth through

development of skills and knowledge, as well as improvement in the facility's performance.

31. Ensures confidentiality of all non-public information and meets any HIPAA

requirements of all records and files

32. Ensures rules and regulations are applied and communicated to staff

33. Utilizes Policy and Procedure Manual effectively

34. Assist staff with interpretations of regulations when needed

35. Anticipates critical events related to workload and makes prior provisions

to deal with them

36. Keeps DON informed of critical events and/or negative outcomes

37. Supports and maintains a culture of safety and quality of care that

complies with State and Federal Regulations

38. Keeps up to date on regulations, policies and procedures and assist in

communication to other staff members

39. Promotes Quality Assessment and Performance Improvement and

Participates in Performance improvement projects when requested.

40. Disposes of drugs and narcotics as required and in accordance with

established procedures; ensure the narcotic records are accurate for your shift.

41. Under the direction of the Director of Nursing, directs the day-to-day

functions of the nursing assistants in accordance with current regulations and policies of the facility.

42. Review NP progress notes and/or consultant providers for recommendations to resident's care. Process recommendations into

orders if necessary. 43.7pm -7 am Charge Nurse will review all New Orders written that day and correct any errors. Once processed print off list of orders reviewed and attached to 24 hour Report.

44. Completes required ICF documentation per policy. Any changes in behaviors or physical condition would be expected to be charted.

45. Maintains inventory of resident drugs and medication on unit.

46. On-coming and out-going nurse reports are timely and thorough.

47. Arranges resident's appointments and transportation timely and appropriate.

48. Makes assignments timely at the beginning of each shift.

49. Maintains appropriate noise level in the facility 100% of time.

50. Notifies physician and DON of any resident's leaving AMA.

51. Report any repairs needed to Maintenance Department timely 100% of time.