About the

Role:

The MDS/RN (Minimum Data Set Registered Nurse) plays a critical role in ensuring the delivery of high-quality care within long-term care and skilled nursing facilities. This position is responsible for conducting comprehensive assessments of residents' health status, which directly informs individualized care planning and regulatory compliance. The MDS/RN collaborates closely with interdisciplinary teams to develop, implement, and monitor care plans that promote optimal resident outcomes and quality of life. Additionally, this role involves meticulous documentation and reporting to meet federal and state guidelines, ensuring the facility maintains compliance with CMS requirements. Ultimately, the MDS/RN serves as a key contributor to both clinical excellence and operational efficiency within the care environment.

Minimum Qualifications:

Current and valid Registered Nurse (RN) or LPN license in the state of employment within the United States. Demonstrated experience with Minimum Data Set (MDS) assessments and knowledge of CMS regulations related to long-term care. Strong clinical background in geriatrics, long-term care, or skilled nursing facility settings. Proficiency in electronic health records (EHR) and clinical documentation systems. Excellent communication and organizational skills.

Preferred Qualifications:

Certification in MDS Coordination or related specialty (e.g., Certified MDS Coordinator). Experience with quality improvement programs and regulatory survey processes. Advanced training or education in gerontology or long-term care nursing. Familiarity with care planning software and data analytics tools. Ability to mentor and train nursing staff on MDS and documentation best practices.

Responsibilities:

Perform thorough and accurate Minimum Data Set (MDS) assessments for residents in accordance with CMS guidelines and facility policies. Collaborate with interdisciplinary team members including physicians, therapists, social workers, and nursing staff to develop and update individualized care plans. Review and analyze clinical data to identify changes in resident conditions and recommend appropriate interventions. Ensure timely and precise documentation of assessments, care plans, and resident progress to maintain compliance with regulatory standards. Provide education and support to nursing staff regarding MDS processes, documentation requirements, and quality improvement initiatives. Participate in quality assurance activities and audits to monitor compliance and improve care delivery. Communicate effectively with residents, families, and healthcare team members to advocate for resident needs and preferences.

Skills:

The MDS/RN utilizes clinical assessment skills daily to evaluate resident health status accurately and comprehensively, ensuring that care plans are tailored to individual needs. Strong communication skills are essential for collaborating with interdisciplinary teams and effectively conveying complex clinical information to staff and families. Proficiency with electronic health records and documentation systems enables the MDS/RN to maintain precise and timely records that comply with regulatory standards. Analytical skills are applied to interpret clinical data and identify trends or changes in resident conditions, facilitating proactive care adjustments. Additionally, leadership and educational skills support the MDS/RN in mentoring nursing staff and promoting best practices in assessment and documentation.