Assessment Nurse

Job Summary :
The Assessment Nurse plays a critical role in ensuring residents are appropriately placed within our Assisted Living community. This position utilizes clinical expertise to assess prospective residents prior to move-in, complete follow-up assessments in accordance with policy, and initiate Health Service Plans for those receiving third-party services. The Assessment Nurse is also responsible for tracking resident progress, updating care levels, and coordinating with other departments to ensure accurate and timely care delivery.

Key Responsibilities :

Resident Assessments and Admissions:

• Review Discovery forms and accompanying documentation submitted by the Sales and Marketing team through the assessment request process.

• Schedule and complete admission assessments promptly upon receipt of documentation.

• Present findings to the Director of Nursing for admission determination.

• Review all denial decisions with the Administrator prior to processing.

Required Assessments :
Maintain current and complete resident documentation, including the following:

1. General Service Evaluation (GSE):

2. A comprehensive 9-page evaluation packet, updated upon admission and every six months or as needed.

3. Includes:

4. Wellness baseline

5. Pain assessment

6. Mobility management planning

7. Self-medication assessment

8. Elopement risk evaluation

9. Mini-mental evaluation

10. Level of Care assessment (notify AL Coordinator and Business Office Manager of any updates)

11. General Service Plan (GSP):

12. Completed using the electronic system (Visual).

13. Printed, signed, and filed in both the GSP binder and resident file upon each update.

14. Health Care Plan (HCP):

15. Initiated for residents receiving third-party services.

16. Communicate all clinical findings and ADL (Activities of Daily Living) needs to the DON and AL Coordinator.

17. Complete assessments at least every six months and whenever there is a change in resident condition.

18. Notify families/POA/residents of any level-of-care changes.

19. Inform billing department of any changes to ensure accurate charges.

Documentation & Compliance :

• Maintain all assessments and plans in designated binders (GSE, GSP, HCP) and bring them to the weekly Level of Care (LOC) meeting.

• Ensure all assessments are signed and reviewed by the RN.

• Organize documentation professionally and accurately.

• Record all communications with families, POAs, residents, and physicians.

Other Duties :

• Support the mission and uphold the values of the community in all interactions.

• Maintain resident confidentiality and adhere to HIPAA standards.

• Project a professional and compassionate demeanor with residents, families, guests, and staff.

• Keep the work environment clean, safe, and organized.

• Collaborate effectively with team members and demonstrate mutual respect and professionalism.

• Take prompt and appropriate action in response to issues or concerns.

• Anticipate and proactively address the needs of residents, guests, and fellow associates.

• Remain open to feedback, new ideas, and continuous improvement.

Qualifications :

• Licensed PN (Practical Nurse) or Licensed RN (Registered Nurse) in good standing.

• Prior experience in assisted living, senior care, or healthcare assessments strongly preferred.

• Strong communication, organizational, and documentation skills.

• Ability to work collaboratively and independently.

• Familiarity with HIPAA guidelines and regulatory compliance.

Avesta Systems periodically recruits for other companies.

NO AGENCY CALLS PLEASE