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Scope · Cedar Ridge Care Center

Ask about weights, alerts, supplements or a unit. A fixed question is answered by the rules engine. Anything else is reasoned by a language model from the building's computed facts, never from names.

Everything I can answer

Fixed questions are answered by the rules engine. Anything else is reasoned by a language model over de-identified computed facts. No name, room or date of birth leaves the building, and every figure is checked.

Reports · Clinical risk

Readmission risk

Every resident in care ranked for nutrition-related readmission risk (a return from hospital, a loss on the scale, the hydration pattern, malnutrition, a tube, a wound, a swallow) and every hospital transfer the record shows, read backwards for what was flagged before it. Who to plan for, not a prediction.

CSV

High risk

Watch

Flagged first

2 of 4

last 180 days

This ranks who to plan for; it does not predict who goes back.

Residents at high or watch readmission risk

15 high, 11 watch, 26 low of 52 in care. Points are ours and versioned: a return from hospital, a prior transfer, a significant loss (or the malnutrition characteristic it meets, counted once), a coded malnutrition diagnosis and high hydration risk weigh 3; a tube, a wound, a swallow and a plain new admission weigh 2; age and a hydration watch weigh 1. Six is high, four is watch, and high needs at least one change (a return, a new stay, a loss, the hydration pattern), because a wound, a swallow and old age describe half a building. This ranks who to plan for; it does not predict who goes back.

Group byRisk Unit

Resident	Risk	Points	Why

Hospital transfers in the last 180 days: what the record showed before each

4 transfers; 2 had an alert open on the day or opened in the 30 days before, median lead 12 days; on 1 the scale alone showed a 5% loss over the prior 30 days. Read on the day, with no hindsight.

Resident	Left	Discharged to	Returned (days)	Flagged first	Lead (days)	Scale, prior 30d
Kaminski, Vivian Cedar (skilled)	12 Oct	Hospital - Acute Care	1	Loss

Cedar Ridge Care Center · generated 19 Oct 16:53 ET · 30 rows. Every figure comes from the rules engine, not from the copilot.

42 CFR 483.25(g) · F692 · SNF QRP readmission measure · ruleset f692-2026.09-v2, metrics flow-2026.09-v1

High · 15
Abernathy, Mildred Cedar (skilled) · 146-A	High	10	Lost 6.1% over 30 days: significant and, until the dietitian rules, unplanned. Malnutrition on the problem list. A pressure injury or wound on the problem list: raised protein needs. Dysphagia or another swallowing diagnosis.	557	107.6
Nakamura, Clarence Cedar (skilled) · 131-A	High	10	Meets the weight-loss characteristic of malnutrition, with no diagnosis coded. Tube-fed: aspiration and tolerance are both return routes. Dysphagia or another swallowing diagnosis. This stay followed acute care. A hydration risk factor on the record. 85 or over.	40 · from hospital	118.6
Oyelaran, Mildred Maple (long-term) · 123-B	High	10	Lost 7.8% over 90 days: significant and, until the dietitian rules, unplanned. Malnutrition on the problem list. A pressure injury or wound on the problem list: raised protein needs. A hydration risk factor on the record. 85 or over.	811	97.9
Kaminski, Vivian Cedar (skilled) · 119-A	High	9	Returned from hospital 6 days ago: the post-acute window, when a return is most likely. Lost 6.4% over 30 days: significant and, until the dietitian rules, unplanned. Malnutrition on the problem list.	6 · from hospital	174.4
Kaminski, Doris Maple (long-term) · 147-A	High	8	Lost 7.5% over 30 days: significant and, until the dietitian rules, unplanned. Malnutrition on the problem list. Dysphagia or another swallowing diagnosis.	612	172.4
Nakagawa, Edith Maple (long-term) · 120-A	High	8	Lost 5.3% over 30 days: significant and, until the dietitian rules, unplanned. Malnutrition on the problem list. A hydration risk factor on the record. 85 or over.	127	112.2
Blackwood, Doris Maple (long-term) · 135-B	High	7	Lost 5.9% over 30 days: significant and, until the dietitian rules, unplanned. Meets the weight-loss characteristic of malnutrition, with no diagnosis coded. Reads as high hydration risk from the record. 85 or over.	805	202.2
Kowalski, Doris Cedar (skilled) · 134-A	High	7	Lost 6.2% over 30 days: significant and, until the dietitian rules, unplanned. Meets the weight-loss characteristic of malnutrition, with no diagnosis coded. Reads as high hydration risk from the record. 85 or over.	799	117.7
Lindqvist, Doris Cedar (skilled) · 149-A	High	7	Lost 8.1% over 30 days: significant and, until the dietitian rules, unplanned. Malnutrition on the problem list. 85 or over.	774	194.4
Okonkwo, Frank Willow (memory care) · 136-A	High	7	Lost 5.4% over 30 days: significant and, until the dietitian rules, unplanned. Meets the weight-loss characteristic of malnutrition, with no diagnosis coded. Dysphagia or another swallowing diagnosis. A hydration risk factor on the record. 85 or over.	344	132.3
Ramaswamy, Herbert Cedar (skilled) · 122-B	High	7	Lost 5.1% over 30 days: significant and, until the dietitian rules, unplanned. Malnutrition on the problem list. 85 or over.	743	153.4
Bhattacharya, Eleanor Cedar (skilled) · 101-B	High	6	Returned from hospital 12 days ago: the post-acute window, when a return is most likely. Lost 7.3% over 30 days: significant and, until the dietitian rules, unplanned. Meets the weight-loss characteristic of malnutrition, with no diagnosis coded.	12 · from hospital	184.3
Castellano, Bernice Cedar (skilled) · 128-A	High	6	Returned from hospital 14 days ago: the post-acute window, when a return is most likely. Lost 10.4% over 180 days: significant and, until the dietitian rules, unplanned. Meets the weight-loss characteristic of malnutrition, with no diagnosis coded.	14 · from hospital	126.1
Underwood, Agnes Willow (memory care) · 124-A	High	6	Lost 9.6% over 90 days: significant and, until the dietitian rules, unplanned. Malnutrition on the problem list.	837	195.1
Underwood, Cecil Willow (memory care) · 121-B	High	6	Lost 5.0% over 30 days: significant and, until the dietitian rules, unplanned. Malnutrition on the problem list.	632	153.4
Watch · 11
Kowalski, Bernice Willow (memory care) · 148-A	Watch	6	Tube-fed: aspiration and tolerance are both return routes. Dysphagia or another swallowing diagnosis. A hydration risk factor on the record. 85 or over.	605	97.9
Castellano, Walter Willow (memory care) · 139-A	Watch	5	Meets the weight-loss characteristic of malnutrition, with no diagnosis coded. A hydration risk factor on the record. 85 or over.	554	181.4
Nakagawa, Walter Maple (long-term) · 129-B	Watch	5	Lost 8.2% over 90 days: significant and, until the dietitian rules, unplanned. A hydration risk factor on the record. 85 or over.	538	123.2
Sandoval, Clarence Maple (long-term) · 132-A	Watch	5	Lost 7.1% over 30 days: significant and, until the dietitian rules, unplanned. Meets the weight-loss characteristic of malnutrition, with no diagnosis coded. Dysphagia or another swallowing diagnosis.	696	152.8
Underwood, Harold Willow (memory care) · 145-A	Watch	5	Admitted 20 days ago: a new stay and a new diet, with no weight history here. A pressure injury or wound on the problem list: raised protein needs. 85 or over.	20	144.4
Ashworth, Eleanor Willow (memory care) · 118-B	Watch	4	Meets the weight-loss characteristic of malnutrition, with no diagnosis coded. 85 or over.	489	226.4
Delacroix, Agnes Maple (long-term) · 111-A	Watch	4	Dysphagia or another swallowing diagnosis. A hydration risk factor on the record. 85 or over.	557	137.8
Ferreira, Beatrice Willow (memory care) · 106-B	Watch	4	Lost 6.9% over 30 days: significant and, until the dietitian rules, unplanned. Meets the weight-loss characteristic of malnutrition, with no diagnosis coded. 85 or over.	594	215.6
Kowalski, Doris Maple (long-term) · 144-B	Watch	4	Admitted 30 days ago: a new stay and a new diet, with no weight history here. A pressure injury or wound on the problem list: raised protein needs.	30	174.2
Petrov, Lorraine Cedar (skilled) · 143-B	Watch	4	Admitted 24 days ago: a new stay and a new diet, with no weight history here. A pressure injury or wound on the problem list: raised protein needs.	24	186.5
Sandoval, Mildred Willow (memory care) · 109-B	Watch	4	Lost 7.9% over 30 days: significant and, until the dietitian rules, unplanned. Meets the weight-loss characteristic of malnutrition, with no diagnosis coded. 85 or over.	506	194.2