Thank you for the opportunity to review this manuscript. This study addresses a clinically relevant topic using a substantial multi-site dataset and attempts to quantify care needs for hospitalized adults with cognitive impairment. While the research provides descriptive data, the novelty is limited as findings largely confirm existing clinical knowledge, and several critical methodological issues need to be addressed. I have some suggestions for improvement.
Abstracts
1. I suggest that the authors add the timeframe of the study to the methods section of the abstract.

Background and introduction
1. The background fails to convincingly justify why this study was necessary when the association between cognitive impairment and care needs is already well-established. Please clarify what specific knowledge gaps this study addresses beyond confirming existing clinical knowledge.

Methods
1. (page 5, line 12) Please provide additional details in the methods section regarding the specific definition or criteria used to classify patients as being in a “critical condition” for exclusion purposes.
2. (page 6, lines 5-6) Please provide (a) total number of auditors across all sites, (b) professional composition with specific numbers, (c) baseline experience with cognitive or delirium assessment tools, (d) detailed training curriculum including format (face-to-face vs online) and trainer qualifications.
3. (page 4, lines 54-55) The authors state that verbal consent was obtained. Could you please clarify whether verbal consent was also deemed sufficient for research purposes in this study, or if this standard applies only to routine clinical screening of admitted patients? Please provide justification or reference to relevant ethical approval.
4. (page 5, lines 43-50) The description of “nurse-documented risk of falls, pressure injuries, or malnutrition” lacks sufficient methodological detail. Please clarify whether these risks were assessed using standardized risk assessment tools (e.g., Morse Fall Scale for falls, MNA for nutrition) or if they were based solely on nurses’ subjective concerns or clinical intuition.
5. (Page 6, analysis section) While authors mentions using “t-test (or Mann Whitney U test if non-parametric) for continuous variables,” Table 1 presents all variables in categorical format, and no t-test results are evident. Please solve this discrepancy between stated analytic methods and results.
6. (Page, 6, analysis section) The description of sensitivity analyses is inadequate and lacks essential detail. While the results section states “(page 6, lines 47-48) sensitivity analyses did not alter the direction or significance of findings,” no actual results are presented. Please add more detailed information.

Results
1. The results section is primarily descriptive. Given the potential influence of confounding variables (age, comorbidity, diagnosis, etc.), the study would benefit from multivariable analyses (e.g., logistic regression). This would strengthen the robustness of the findings and support the clinical implications claimed in the discussion.
2. (Table 1) Please include the total sample size in the table title for clarity and specify which statistical test was used for each variable comparison in table footnotes.
3. (Figures 1 and 3) Figures 1 and 3 present essentially the same information in different formats (percentages vs. absolute numbers). Consider retaining only one figure or combining both presentations, as this redundancy may reduce clarity.

Discussion
1. The discussion needs to state why these findings matter beyond confirming what clinicians already know. The clinical implications are overstated given the study's limitations, and the practical recommendations are too generic to be useful.
2. The authors claim ‘association’ between cognitive impairment and care needs, but the univariate analysis without controlling for obvious confounding variables makes it difficult to determine whether observed differences are attributable to cognitive impairment itself or to these confounders. The study demonstrates group differences but not true associations.
3. The manuscript does not include a separate conclusion section as required by the journal's author guidelines for empirical research quantitative articles. According to the provided formatting requirements, a distinct conclusion section should follow the discussion.