Clinical Assessment & Admissions 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):

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

• Wellness baseline
• Pain assessment
• Mobility management planning
• Self-medication assessment
• Elopement risk evaluation
• Mini-mental evaluation
• Level of Care assessment (notify AL Coordinator and Business Office Manager of any updates)

2. General Service Plan (GSP):

• Completed using the electronic system (Visual).
• Printed, signed, and filed in both the GSP binder and resident file upon each update.

3. Health Care Plan (HCP):

• Initiated for residents receiving third-party services.
• Communicate all clinical findings and ADL (Activities of Daily Living) needs to the DON and AL Coordinator
• Complete assessments at least every six months and whenever there is a change in resident condition.
• Notify families/POA/residents of any level-of-care changes.
• 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.