The conditions that led regulators to brand a Northern Ireland care home one of the worst they had ever seen can be revealed.
A team of Regulation and Quality Improvement Authority (RQIA) inspectors visited Valley Nursing Home on December 16 and 17 last year and uncovered harrowing and potentially lethal failings and practices.
Among the issues raised following the two-day visit to the home in Clogher, Co Tyrone, was the use of QR (barcode) labels on residents' doors, which the inspectors described as "dehumanising" - believed to be the first time the term has ever been used in an RQIA inspection report.
The RQIA team was also told by two nurses that all emergency oxygen cylinders had been removed, meaning they were unable to administer oxygen to a resident while waiting for an ambulance.
The report said: "The only oxygen in the home was prescribed for specific patients.
"They cited a recent occasion when the general unit rang staff within the Amadeus unit to enquire if they had oxygen to manage a patient in an emergency but none was available.
"The staff were therefore unable to offer appropriate care as they awaited an ambulance."
The inspectors also raised concerns about the undignified way staff spoke to residents.
The report said: "The food looked and smelled appetising; however, given that the patient group was mainly younger men, the portion sizes may not have been adequate.
"One patient asked a nurse if he could finish someone else's dinner, stating: 'I'm hungry!' "The nurse responded by stating 'you've had your dinner and dessert and that's it!'
"We asked him if he was still hungry and he responded that he was 'starving'.
"Staff, when asked about this, claimed that he was 'always like this' and didn't know when he had had enough to eat.
"However, it was noted that his jeans were loose and he had to hold them up when walking."
Inspectors observed the registered nurse "speaking to patients as if they were children, using a firm and intimidating tone of voice", the report said.
It added: "One patient asked for a drink and was told: 'Sit down! Then I'll get you a drink.'
"On another occasion they were heard to tell a patient off for talking with their mouth full."
Concerns were raised about the way residents were dressed and whether they were being cleaned and cared for properly.
The majority of residents were noted to be wearing tracksuit bottoms with formal shirts and jumpers and some of their jumpers were soiled with food.
The inspectors were also worried about the provision of oral and fingernail care and hair washing of residents.
One resident was seen to have very long and dirty fingernails.
A member of the RQIA team had to ask staff to attend to the eye care of a resident.
The RQIA subsequently held a meeting with management from the home but was not happy that issues could be addressed sufficiently.
As a result, they issued a notice of proposal to cancel the registration of the responsible individual of the home.
The measure meant the home faced closure, however, last month the RQIA announced it was registering a new provider.
RQIA chief executive Olive Macleod said: "This is good news for the Valley's patients, their families and staff at the home who have been failed by the previous management of the home."