Reports

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

1 of 3

last 180 days

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

Residents at high or watch readmission risk

2 high, 11 watch, 40 low of 53 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

3 transfers; 1 had an alert open on the day or opened in the 30 days before, median lead 5 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
Underwood, Cecil Memory care	12 Oct	Hospital - Acute Care	1	Loss

Oak Terrace Health Center · generated 19 Oct 18:24 ET · 16 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

Memory care · 6
Underwood, Cecil Memory care · 145-B	High	11	Returned from hospital 6 days ago: the post-acute window, when a return is most likely. 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.	6 · from hospital	97.7
Kaminski, Clarence Memory care · 151-B	High	6	Admitted 22 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. A hydration risk factor on the record. 85 or over.	22	210.5
Bhattacharya, Clarence Memory care · 142-B	Watch	5	Lost 7.5% over 30 days: significant and, until the dietitian rules, unplanned. Meets the weight-loss characteristic of malnutrition, with no diagnosis coded. A hydration risk factor on the record. 85 or over.	878	144.2
Ramaswamy, Edith Memory care · 127-A	Watch	5	Lost 5.6% 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.	303	188.1
Kaminski, Herbert Memory care · 139-A	Watch	4	Lost 5.3% over 30 days: significant and, until the dietitian rules, unplanned. Meets the weight-loss characteristic of malnutrition, with no diagnosis coded. 85 or over.	302	171.7
Nakamura, Cecil Memory care · 136-A	Watch	4	Dysphagia or another swallowing diagnosis. A hydration risk factor on the record. 85 or over.	607	140.7
South wing · 1
Ferreira, Mildred South wing · 147-A	Watch	6	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.	40 · from hospital	142.6
North wing · 6
Bhattacharya, Edith North wing · 101-B	Watch	5	Returned from hospital 12 days ago: the post-acute window, when a return is most likely. Dysphagia or another swallowing diagnosis.	12 · from hospital	159
Kaminski, Frank North wing · 149-A	Watch	5	Lost 6.3% over 30 days: significant and, until the dietitian rules, unplanned. Meets the weight-loss characteristic of malnutrition, with no diagnosis coded. A hydration risk factor on the record. 85 or over.	431	120.4
Lindqvist, Herbert North wing · 107-A	Watch	5	Lost 6.4% over 30 days: significant and, until the dietitian rules, unplanned. Meets the weight-loss characteristic of malnutrition, with no diagnosis coded. A hydration risk factor on the record. 85 or over.	826	112.9
Ramaswamy, Leonard North wing · 146-B	Watch	5	Lost 7.8% over 90 days: significant and, until the dietitian rules, unplanned. Meets the weight-loss characteristic of malnutrition, with no diagnosis coded. A hydration risk factor on the record. 85 or over.	171	193.1
Delacroix, Stanley North wing · 104-A	Watch	4	Dysphagia or another swallowing diagnosis. A hydration risk factor on the record. 85 or over.	510	165.6
Ferreira, Leonard North wing · 116-B	Watch	4	Dysphagia or another swallowing diagnosis. A hydration risk factor on the record. 85 or over.	235	192.9