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Thank you for the clarification. While the article does specify that the Centers for Medicare and Medicaid Services uses the MDS-RAI "to calculate quality ratings for all certified nursing homes," you are correct that the MDS-RAI assessment items don't include residents who are not in federally certified nursing home beds. But it's uncertain that the absence of these data would bias the findings from the MDS-RAI. My clinical and research experience with those facilities that are not required to use the MDS-RAI suggests that their medical record documentation is often inadequate and less accurate than that used in the MDS-RAI. Thus, if anything, the MDS-RAI may provide a clearer view of reality.