Registered Nurse

Job Description

Job Description

Location: Oak Hills Manor, LLC
Oak Hills, California

Reports To: Director of Nursing

FLSA Class: Salary, Exempt

WC Code: 8829

Position Summary:

The Registered Nurse (RN) is responsible for providing safe, compassionate, and individualized nursing care to residents of Oak Hills Manor, LLC, a Congregate Living Health Facility (CLHF). The RN provides direct nursing care, performs clinical assessments, administers medications and treatments as ordered, develops and evaluates individualized plans of care, monitors residents for changes in condition, and communicates clinical information to physicians, healthcare providers, residents, families, and other members of the care team.

The RN performs nursing duties in accordance with applicable California Title 22 regulations, California Department of Public Health (CDPH) requirements, applicable federal laws and regulations, physician orders, professional nursing standards, and facility policies and procedures.

The RN exercises professional judgment within the scope of the California Registered Nurse license and works collaboratively with the interdisciplinary healthcare team to promote resident health, safety, dignity, comfort, and quality of life.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

Direct Resident Care

• Provide skilled nursing care to residents in accordance with physician orders, individualized care plans, facility policies, and applicable regulations.
• Supervise and provide clinical direction to Licensed Vocational Nurses (LVNs) and Certified Nursing Assistants (CNAs), ensuring assigned duties are performed safely and within their respective scopes of practice.
• Assign, delegate, and monitor nursing responsibilities based on resident needs, staff qualifications, and applicable regulatory requirements.
• Perform initial, ongoing, and focused nursing assessments based on resident condition and identified needs.
• Monitor residents for changes in physical, mental, emotional, and functional condition.
• Recognize and promptly report significant changes in resident condition to the appropriate physician, healthcare provider, Administrator, resident representative, or other responsible party as required.
• Develop, implement, and evaluate individualized nursing care plans based on resident needs and physician orders.
• Provide nursing interventions and treatments within the scope of the RN's license and in accordance with physician orders.
• Monitor resident responses to treatments and interventions and report adverse reactions or concerns promptly.
• Promote resident comfort, dignity, independence, and quality of life.
• Assist with the prevention and management of falls, pressure injuries, infections, dehydration, and other preventable complications.
• Provide appropriate nursing care during emergency situations and follow established emergency response procedures.
  

Medication Administration and Treatments

• Administer medications safely and accurately in accordance with physician orders, applicable regulations, and facility policies.
• Verify medication orders and monitor residents for therapeutic effects, adverse reactions, side effects, and other medication-related concerns.
• Perform treatments and nursing procedures within the scope of practice and according to physician orders.
• Maintain accurate medication administration and treatment records.
• Report medication errors, adverse reactions, and other medication-related concerns promptly and in accordance with facility policies and applicable regulations.
• Communicate with physicians, pharmacies, and other healthcare providers regarding medication and treatment needs.
• Ensure medications and treatments are administered in a manner that promotes resident safety and follows established infection-control practices.
  

Documentation and Medical Records

• Maintain accurate, timely, complete, and confidential nursing documentation in resident medical records and the Electronic Health Record (EHR), as applicable.
• Document assessments, interventions, medications, treatments, changes in condition, resident responses, and communications with healthcare providers.
• Complete required nursing notes, incident reports, assessments, and other clinical documentation.
• Ensure documentation accurately reflects the care provided and the resident's current condition.
• Maintain confidentiality of resident information in accordance with applicable privacy laws and facility policies.
  

Care Coordination and Communication

• Communicate effectively with physicians, nurse practitioners, therapists, pharmacists, CNAs, LVNs, other healthcare professionals, residents, and resident representatives.
• Participate in interdisciplinary care planning and communicate relevant clinical information to members of the healthcare team.
• Coordinate physician appointments, consultations, hospital transfers, follow-up care, and other healthcare services as directed.
• Communicate changes in resident condition promptly and accurately.
• Provide residents and families with appropriate information regarding nursing care, medications, treatments, and changes in condition within the RN's scope of practice.
• Advocate for resident needs, preferences, rights, dignity, and safety.
• Maintain professional and respectful communication with residents, families, visitors, coworkers, and healthcare providers.

Infection Prevention and Control

• Follow facility infection prevention and control policies and procedures.
• Practice appropriate hand hygiene and use personal protective equipment as required.
• Monitor residents for signs and symptoms of infection and promptly report concerns.
• Follow isolation precautions and other infection-control measures when indicated.
• Assist with infection prevention activities and follow applicable facility and regulatory requirements.
• Properly dispose of medications, sharps, biohazardous materials, and other regulated waste in accordance with facility procedures.
  

Resident Safety and Emergency Response

• Maintain awareness of resident safety risks and take appropriate measures to reduce preventable injuries and complications.
• Follow facility procedures related to fall prevention, pressure injury prevention, emergency preparedness, and resident safety.
• Respond appropriately to medical emergencies and changes in resident condition.
• Complete and document incident reports as required.
• Promptly report suspected abuse, neglect, exploitation, or other reportable concerns in accordance with applicable laws and facility policies.
• Maintain a safe environment for residents, staff, and visitors.
  

Regulatory and Professional Responsibilities

• Perform nursing services in accordance with California Title 22 regulations, CDPH requirements, applicable federal regulations, physician orders, and facility policies and procedures.
• Maintain an active California Registered Nurse license and all required certifications.
• Practice within the scope of the California RN license and applicable professional standards of nursing practice.
• Maintain knowledge of current nursing practices, applicable regulations, infection-control requirements, resident rights, and facility policies.
• Participate in required in-service education, competency training, and continuing education.
• Protect resident privacy, confidentiality, dignity, and rights.
• Cooperate with facility quality assurance activities and regulatory requirements related to resident care.
• Maintain professional competence and seek appropriate assistance or consultation when resident needs exceed the RN's knowledge, experience, or scope of practice.
  

Teamwork and Professional Conduct

• Work collaboratively with CNAs, LVNs, physicians, and other members of the healthcare team.
• Provide appropriate clinical guidance to nursing assistants and other staff regarding resident care within the RN's scope of responsibility.
• Promote effective communication and continuity of care among members of the healthcare team.
• Demonstrate sound clinical judgment, accountability, reliability, and professionalism.
• Maintain a compassionate, respectful, and resident-centered approach to care.
• Exercise discretion and independent professional judgment within the scope of the RN position.
• Perform other related duties as assigned.

Education & Certification:

• Current, active Registered Nurse (RN) license in the State of California.
• Associate Degree in Nursing (ADN) or Bachelor of Science in Nursing (BSN) required, consistent with applicable requirements.
• Current Basic Life Support (BLS) certification required.
• Maintain all licenses, registrations, and certifications required for the position.

Experience:

• Minimum of two (2) years of experience as a Registered Nurse preferred.
• Experience in a Congregate Living Health Facility, skilled nursing, long-term care, rehabilitation, acute care, or similar healthcare setting preferred.
• Experience with medication administration, nursing treatments, clinical assessments, care planning, and electronic health records preferred.
• Knowledge of California Title 22 regulations and California Department of Public Health (CDPH) requirements preferred.
• Experience caring for medically complex, chronically ill, or dependent residents preferred environment.

Skills & Abilities:

• Strong understanding of Title 22 regulations, infection control procedures, and healthcare standards
• Exceptional leadership and interpersonal skills with the ability to manage a diverse team
• Excellent written and verbal communication skills
• Proficient in using Electronic Health Records (EHR) systems and basic office software
• Strong organizational and time-management skills with the ability to manage multiple tasks and priorities effectively
• Compassionate and patient-centered approach to care

WORKING CONDITIONS

• Full-time position. Some evening and weekend availability may be required
• Must be able to work in a fast-paced environment, including during emergency