Care Plan Nurse-MDS RN

AVIR Health Group is seeking a qualified MDS Registered Nurse (RN) to join our family!

We are seeking a detail-oriented and resident-centered MDS Registered Nurse (RN) with a primary focus on care planning. In this role, you will be responsible for developing, coordinating, and maintaining comprehensive, individualized care plans that ensure each resident receives high-quality, person-centered care in accordance with regulatory standards.

This position is ideal for an RN who excels in interdisciplinary collaboration, documentation accuracy, and ensuring that care delivery aligns with each resident’s unique needs.

• Develop, implement, and maintain individualized care plans based on resident assessments, diagnoses, physician orders, and interdisciplinary input

• Lead and coordinate care plan meetings with the interdisciplinary team, residents, and family members

• Ensure care plans reflect residents’ physical, emotional, psychosocial, and restorative needs

• Update care plans promptly with any significant change in condition, new orders, or regulatory requirements

• Ensure nursing staff are informed of and follow all care plan interventions

• Audit and monitor care plan documentation for accuracy, completeness, and compliance

• Collaborate with MDS Coordinators and IDT members to ensure care plans align with MDS assessments and RAI guidelines

• Participate in Quality Assurance (QA/QAPI) activities related to care planning and resident outcomes

• Educate nursing staff on care plan interventions and documentation expectations

• Ensure compliance with federal, state, and facility regulations
  , including CMS guidelines for long-term care

• Active Registered Nurse (RN) license in good standing

• Minimum 1–2 years of experience in long-term care or skilled nursing facility preferred

• Experience with
  MDS 3.0 and RAI process strongly preferred

• Strong knowledge of care planning regulations and CMS guidelines

• Excellent documentation, organizational, and communication skills

• Ability to work collaboratively with an interdisciplinary team

• Experience leading care plan meetings

• Strong attention to detail and regulatory compliance

• Ability to analyze clinical data and translate it into actionable care plans

• Knowledge of EMR systems used in long-term care

This role is centered on ensuring that every resident has a comprehensive, accurate, and actionable care plan that drives daily care delivery. The MDS RN (Care Plan Focus) plays a critical role in bridging clinical assessments with hands‑on care, ensuring consistency, compliance, and quality outcomes across the facility.

Avir Health Group is an equal opportunity employer. All applicants will be considered for employment without regard to race, color, religion, sex, sexual orientation, gender identity,