Health inspection·August 14, 2019

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to report a change of condition to the attending physician for one of 19 sampled residents (23), when the saturation levels (oxygen level in the blood) registered below the average normal range of between 95 to 100 percent (%). This deficient practice had the potentially caused a delay of medical treatment for Resident 23. Findings: A review of Resident 23's face sheet indicated an original admission date of 11/19/18 and a readmission date of 04/18/19 with diagnoses including chronic respiratory failure (a long-term condition that happens when your lungs can not get enough oxygen into your blood) with hypoxia (a condition in which the body or a region of the body is deprived of adequate oxygen supply at the tissue level, chronic obstructive pulmonary disease ([COPD] a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and respiratory tuberculosis (a contagious infection caused by bacteria that mainly affects the lungs but also can affect any other organ). A review of Resident 23's History and Physical assessment from the physician dated 04/22/19 indicated the resident was hospitalized for acute chronic hypoxemia, hypercapneic (a condition of abnormally elevated carbon dioxide levels in the blood), and COPD. A review of Resident 23's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated for 02/28/19 indicated the resident had intact level of cognition (process of acquiring knowledge and understanding) for daily decision making. A review of Resident 23's Physician Orders dated 03/25/19 included the following: - Monitor oxygen saturation every shift, maintain oxygen saturation to 90 % and or above at all times. - Advair Diskus (medicine used for COPD) aerosol powder 250-50 microgram (mcg) dose, 1 puff, twice a day (BID) - Singulair (medicine to prevent the wheezing and shortness of breath) 10 milligram (mg), at bedtime, and - Oxygen (O2) at 2 liters per minute (LPM) for O2 less than 90 %. Page 1 of 13 555780 555780 08/14/2019 Villa Del Rio Gardens 7004 East Gage Avenue Bell Gardens, CA 90201

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident 23's Medication Administration Record (MAR) for April 2, 2019 indicated the resident had an O2 saturation of 80 % on 11 p.m. to 7 a.m. shift. The MAR further indicated Resident 23's O2 saturation was 86 % at 6 a.m., while receiving oxygen. A review of Resident 23's MAR for April 8, 2019 indicated the resident had an O2 saturation of 80 % on 11 p.m. to 7 a.m. shift. The MAR further indicated the resident's O2 saturation was 88 % at 6 a.m., while receiving oxygen and the resident was redirected to breath through the nose. On 08/14/19 at 9:17 a.m., during a concurrent interview and record review, Licensed Vocational Nurse (LVN 1) stated the nurse should have contacted the physician when the resident had an oxygen level of 86 % and 88 % on 4/2/19 and 4/8/19, respectively. LVN 1 also stated there was no documentation in the resident's records indicating the facility notified the attending physician. LVN also stated, I would have called as soon as it reached less than that. On 08/14/19, at 9:27 a.m., during an interview, the Director of Nursing (DON) stated the physician should have been contacted as soon as the nurse had to use the supplemental oxygen to increase Resident 23's blood oxygen saturation levels. A review of Resident 23's medical record indicated the resident was sent to the hospital on [DATE] for respiratory distress with a low oxygen saturation of 68 % while receiving supplemental oxygen at 2 liters per minute. A review of Resident 23's care plan dated 3/26/19 indicated under concerns and problems, Resident at risk for shortness of breath (SOB), anxiety from dyspnea, diminished ability to perform activities of daily living (ADLs) due to: COPD. The care plan listed the resident's goals as Resident will display optimal breathing pattern daily. Will minimize signs and symptoms of acute respiratory insufficiency: anxiety, confusion, restlessness, SOB, cyanosis, and somnolence. The approaches on the plan of care included, Monitor for symptoms of acute respiratory insufficiency and notify MD promptly. A review of Resident 23's care plan dated 3/26/19 indicated under concerns and problems, Resident requires oxygen use related to history of COPD. The care plan listed the resident's goals as Resident will be able to participate/perform ADLS without signs and symptoms of SOB on a daily basis. The approach of the care plan included, Provide O2 at 2 liters per minute by nasal cannula. Monitor for episodes of SOB. Check oxygen saturation every shift. Teach resident breathing techniques purse lip, cough and deep breathing. Monitor labs and notify MD. A review of Resident 23's interdisciplinary team (professionals who assess, coordinate, and manage each resident's comprehensive health care, including his or her medical, psychological, social, and functional needs) meeting conference form dated 3/27/19 indicated, .He was recently re-admitted from hospital following treatment for COPD exacerbation. Resident continues to require the use of O2 .O2 sat continues to decline with minimal exertion . A review of Resident 23's nurses notes for 4/14/19 at 7 a.m. indicated, Vital signs (V/S) 140/70 milligram per deciliter, pulse 77, respiration 23, temp 99.3, O2 stat was 68% on continuous 2L of oxygen via NC (nasal cannula; device used to deliver oxygen thru the nose); sent out 911 per MD order because of desaturation; skin was pale, and clammy; no SOB noted; resident denied pain, no s/s (signs and symptoms) of distress noted. A review of Resident 23's face sheet from the emergency room (ER) dated 4/15/19 indicated the 555780 Page 2 of 13 555780 08/14/2019 Villa Del Rio Gardens 7004 East Gage Avenue Bell Gardens, CA 90201

F 0580 reason of the visit, Acute chronic obstructive pulmonary disease exacerbation with hypoxemia/hypercapnia. Level of Harm - Minimal harm or potential for actual harm A review of Resident 23's history and physical from the acute hospital, dated 4/15/19, indicated under history of present illness: As per patient, for the last 2 or 3 days, he has been having progressive worse shortness of breath with significant wheezing as well as a cough which is predominantly dry, but occasionally productive of whitish to tan colored sputum. Upon presentation in the ER, he was found to be hypoxemic requiring high flow nasal cannula to maintain his saturation above ninety percent. Residents Affected - Few A review of the facility's undated policy and procedure titled, Notification of Changes, indicated, .The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notify, consistent with his or her authority, resident's representative when there is a change requiring notification .Compliance Guidelines .Circumstances requiring notification include .Significant change in the resident's physical, mental, or psychosocial condition such as deterioration in health, mental or psychosocial status . This may include .life-threatening conditions, or clinical complications . 555780 Page 3 of 13 555780 08/14/2019 Villa Del Rio Gardens 7004 East Gage Avenue Bell Gardens, CA 90201

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to develop a plan of care for the use of Depakote (medication used as a mood stabilizer), for major depression disorder manifested by self-isolation for one of 19 sampled residents (66). This deficient practice placed Resident 66 at increased risk for adverse reactions for the use of Depakote and psychological harm related to isolation. Findings: A review of Resident 66's face sheet indicated the resident was readmitted to the facility on [DATE] with diagnoses including Alzheimer's disease (chronic brain disease that usually starts slowly and gradually worsens over time characterized by difficulty in remembering recent events, problems with language, disorientation and mood swings), major depressive disorder (a mental disorder characterized by low mood, accompanied by low self-esteem, loss of interest in normally enjoyable activities), and dementia (memory loss) with behavioral disturbance. A review of Resident 66's Physician Orders dated 7/16/19 indicated an order of Depakote, 125 milligram by mouth two times a day for major depression disorder manifested by self-isolation. A review of Resident 66's Psychotherapy Progress notes dated 07/09/19 indicated a therapeutic goal of decreased social Isolation/withdrawal and decreased depression. A review of Resident 66's Social Service Assessment notes dated 7/13/2019, indicated the resident was withdrawn. However, a review of Resident 66's Care plans did not show a plan of care developed for the identified behavior of social isolation/withdrawn, and to identify interventions to decrease the episodes for the use of Depakote. On 8/13/2019 at 3:55 p.m., during an interview the Assistant Director of Nursing (ADON) stated all psychotropic medications should have a care plan to help staff identify, and prevent adverse reactions from psychotropic medications. The ADON also stated a plan of care was not developed for Resident 66 related to the identified behavior of isolation. The ADON also state there are no interventions to prevent further episodes of isolation. A review of an undated facility's policy and procedure titled, Care Plan -Comprehensive, indicated each resident's comprehensive care plan is designed to incorporate risk factors associated with identified problems and aid in preventing or reducing declines in the resident's functional status and/or functional level. 555780 Page 4 of 13 555780 08/14/2019 Villa Del Rio Gardens 7004 East Gage Avenue Bell Gardens, CA 90201

F 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview, and record review, the facility failed ensure a Registered Nurse (RN) was on duty, for at least eight consecutive hours a day, for three consecutive days (August 11, 12 and 13, 2019). Residents Affected - Few This deficient practice had the potential for the residents not be provided with the appropriate nursing observations, and assessments, which could only be performed by an RN. Findings: A review of the Daily Nursing hours' projection sheet that included the day shift, evening shift, and night shift, dated August 11, 12, and 13, 2019 did not indicate an RN, who was scheduled to work in the facility. On 8/14/19 at 10:01 a.m., during an interview, the Administrator stated the facility did not have a waiver for nurse staffing (to assure that sufficient qualified nursing staff are available on a daily basis to meet residents' needs for nursing care in a manner and in an environment which promotes each resident's physical, mental and psychosocial well-being, thus enhancing their quality of life). The Administrator stated the facility did not have a required RN, for at least eight hours per day, which usually happens on the weekends. The Administrator stated the facility needed to have a RN at least 8 hours a day, 7 days a week, because they usually have 70 or more residents in the facility. The Administrator further stated they were in the process of screening applicants for an RN staff position. A review of an undated facility's policy and procedure titled, Nursing Services and Sufficient Staff, indicated it was the policy of the facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial wee-being of each resident. The policy further indicated that except when waived, the facility must use the services of a registered nurse for at least eight consecutive hours a day, 7 days a week. 555780 Page 5 of 13 555780 08/14/2019 Villa Del Rio Gardens 7004 East Gage Avenue Bell Gardens, CA 90201

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview, and record review, the facility failed to prepare the appropriate consistency of a breaded chicken for a residents who was on a mechanical soft diet (a diet that involves only foods that are physically soft, with the goal of reducing or eliminating the need to chew the food), per the menu, and the physician order. This deficient practiced of not grinding, but cutting the breaded chicken in to one-inch or bigger size, had the potential to place the residents who was to receive mechanical soft diet, at increased risk for choking. Findings: On 8/13/2019 at 12:07 p.m., during the tray line observation, kitchen staff cut the breaded chicken with a spatula into one-inch or bigger cuts. During observation the kitchen staff placed the cut breaded chicken on the tray of a resident that had an order for mechanical soft diet. A review of the facility's Summer Menus spreadsheet dated 8/13/19 indicated on the same day, the residents were to be served baked chicken with cordon bleu cheese sauce for lunch. However, the Summer Menus spreadsheet indicated to grind the baked chicken for mechanical soft diet orders, and not cut it into one-inch or bigger cuts. A review of the facility's Recipe for baked chicken with cordon bleu cheese sauce indicated to grind and serve to the residents who had a physician order for mechanical soft diet. On 8/13/2019 at 12:09 p.m., during an interview, the Assistant Dietary Supervisor (ADS 2) also acknowledged cut pieces of baked chicken were assessed to be too big for a resident who had an order for mechanical soft diet. The ADS 2 stated the cut pieces of baked chicken were not the proper consistency for the resident who was to be served a mechanical soft diet. A review of an undated facility's policy and procedure, titled Therapeutic Diet Orders, indicated therapeutic diets will be provided to residents in the appropriate form and/or the appropriate nutritive content as prescribed by the physician and/or assessed by the interdisciplinary team to support the treatment and plan of care. 555780 Page 6 of 13 555780 08/14/2019 Villa Del Rio Gardens 7004 East Gage Avenue Bell Gardens, CA 90201

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to: a. Maintain the correct concentration of chlorine (a chemical sanitizing agent) sanitizing agent used in the low-temperature dishwasher, according to the manufacturer's guidelines. b. Ensure one Kitchen Staff performed hand washing before starting work, and prior to handling foods, when in the kitchen area. These deficient practices had the potential to increase the risk of food contamination, which could cause foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) for the residents. Findings: a. On 08/08/2019 at 8:24 a.m., during a concurrent observation and interview in the initial kitchen tour, Assistant Dietary Supervisor (ADS 2) checked the concentration of sanitation on the newly washed dishes with a chlorine test strip. The test strip measured less than 10 parts per million ([ppm] unit of concentration). ADS 2 repeated the test process five times on various dishes that came out of the automated dish washer. All five test strip resulted in less than 10 ppm reading. ADS 2 placed a new load of dishes and completed the dish washing cycle. ADS 2 acknowledged the manufacturer's guidelines for proper concentration of chlorine sanitation solution on the dishes was to be 50 ppm. A review of the facility's Kitchen Dishwashing Monitoring log on 08/08/2019 at 9:00 a.m., did not indicate the chlorine chemical sanitizing agent was checked prior to using the automated dishwasher. On 8/08/2019 at 10:20 a.m., during an interview, ADS 2 stated she called the manufacturer help line to trouble shoot the dishwasher sanitation cycle. ADS 2 stated she thought there was a kink in the line that dispensed the chemical sanitizer on the dishes. ADS 2 stated the recommended concentration of sanitizing solution was not properly dispensing into the dish washer, that was why it registered a 10 ppm. ADS 2 also stated staff were improperly trained on how to check for the proper concentration of sanitizer on the dishes. ADS 2 stated that all of the dishes that were washed that morning would be rewashed manually until the problem was corrected. b. On 8/13/2019 at 12:10 p.m., during a tray line observation, Kitchen Staff 2 did not perform hand washing technique, prior to observing the following: Kitchen Staff 2 exited the kitchen into the resident dining area, returned into the kitchen, obtained a bagged package of cup lids from storage room, exited the kitchen, returned into the kitchen, walked to the food preparation area area, and picked up a container of strawberries. On 8/13/2019 at 12:15 p.m , during an interview, Kitchen Staff 2 stated he went in and out of the kitchen without having performed hand washing. Kitchen staff 2 stated he picked up a container of strawberries at the food preparation station. Kitchen Staff 2 stated he we rushing and did not think about it but should have washed his hand upon entering the kitchen. On 8/13/2019 at 12:21 p.m., during an interview, Assistant Dietary Supervisor (ADS 2) stated kitchen staff are trained, with no exceptions, were to wash their hands upon entering the kitchen. ADS 2 555780 Page 7 of 13 555780 08/14/2019 Villa Del Rio Gardens 7004 East Gage Avenue Bell Gardens, CA 90201

F 0812 stated Kitchen staff 2 will be in serviced concerning the hand washing policy. Level of Harm - Minimal harm or potential for actual harm A review of facility's policy, dated 2018, titled Hand Washing Procedure, indicated hands need to be washed before starting work in the kitchen. Residents Affected - Some 555780 Page 8 of 13 555780 08/14/2019 Villa Del Rio Gardens 7004 East Gage Avenue Bell Gardens, CA 90201

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Potential for minimal harm Based on observation, interview, and record review, the facility failed to ensure proper handling of clothes were followed, when clothes was dropped on the floor, folded, and then placed in the resident's closet. Residents Affected - Some This failure had the potential to cause spread of infection to the residents of the facility. Findings: During a concurrent observation, and interview on 08/08/19 at 09:46 a.m., a Certified Nursing Assistant (CNA 20) folded a resident's clothes that was dropped on the floor. CNA 20 folded the clothes, and then placed the resident's clothes in the closet. During an interview CNA 20 stated she was organizing the clean clothes but acknowledged the clean clothes should not be placed on the floor, and or put in the resident's closet. During an interview on 08/13/19 at 9:27 a.m., the Director of Staff Development stated CNAs were taught that neither clean nor dirty linen or clothes should be left on the floor. A review of the facility's undated policy and procedure titled, Handling Soiled Linen, indicated, .Staff shall handle, store, and transport clean linen in a manner to prevent contamination .Guidelines for handling, storage, processing, and transporting linens include, but are not limited to, the following .Linen should not be allowed to touch the uniform or floor . 555780 Page 9 of 13 555780 08/14/2019 Villa Del Rio Gardens 7004 East Gage Avenue Bell Gardens, CA 90201

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to follow its protocols for antibiotic stewardship program (a program designed to optimize the use of antibiotics and reduce the adverse events usually associated with antibiotic use), when administering ciprofloxacin (an antibiotic used to treat infections), to one of 19 sampled residents (47), who did not meet the criteria for antibiotic use while being treated for a urinary tract infection ([UTI] an infection in any part of the urinary system). Residents Affected - Few This deficient practice had the potential to place Resident 47 at risk for the developing antibiotic-resistant organisms (a strain of infectious organisms that developed resistance to antibiotics), and suffer side effects of unnecessary or inappropriate antibiotic use. Findings: A review of the admission Records indicated Resident 47 was admitted on [DATE] and re-admitted on [DATE], with diagnoses including asthma (a condition in which the tubes that carry air in and out of the lung narrow and swell causing obstruction) with exacerbation (getting worst), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (characterized by excessive, uncontrollable and irrational worry about events or activities). A review of Resident 47's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 6/25/19 indicated Resident 47 was severely cognitively (ability to make decisions of daily living) impaired for daily decision making. The MDS assessment indicated Resident 47 required assistance in activities of daily living such as getting dressed, toilet use, and personal hygiene. A review of a physician order dated 7/9/19 indicated an order for ciprofloxacin (an antibiotic used to treat infections) by mouth every 12 hours for 10 days, to be administered to Resident 47 for UTI. A review of the medication administration records dated July 2019 indicated Resident 47 received the ciprofloxacin at 9:00 a.m. and 9:00 p.m. on July 9, 10, 11, 13, 14 and on July 15 at 9:00 p.m. During a concurrent interview, and record review on 8/13/19, at 8:31 a.m. Licensed Vocational Nurse (LVN 1) stated she was responsible for the antibiotic stewardship program. LVN 1 stated as part of the facility antibiotic stewardship program, she documents the date of admission, any signs and symptoms, where the infection was, the medications the resident was on, and whether the resident met the criteria for antibiotic use. LVN 1 stated the facility used the McGeer Criteria. A review of National Institute of Health (a governmental bio-medical research agency), McGeer Criteria was used as a standard of practice that included categories that must be met to determine if a resident was a candidate for antibiotic use. A review of the McGeer's criteria indicated a resident must meet at least two of the following criteria of signs and symptoms of infection to be treated with antibiotics for a suspected urinary tract infection: Positive urine culture, and acute dysuria (pain or discomfort when urinating) or a fever (greater than 100 degrees Fahrenheit) and lower abdominal pain, urinary frequency, blood in the urine, and incontinence). During a concurrent interview, and record review on 08/13/19 8:31 a.m., LVN 1 stated according to McGeer's Criteria, Resident 47 did not meet the criteria for getting antibiotics for a UTI. LVN 1 555780 Page 10 of 13 555780 08/14/2019 Villa Del Rio Gardens 7004 East Gage Avenue Bell Gardens, CA 90201

F 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated Resident 47 had a urine culture test (a test performed to grow and identify organisms that may cause a urinary tract infection) that showed positive for bacteria. However, when compared to McGeer Criteria, a review of Resident 47's medical record indicated the resident did not have fever, urinary urgency, pain, frequency, incontinence, or blood in the urine to qualify and justify the use of ciprofloxacin. During an interview on 8/13/19 at 8:58 a.m., LVN 1 acknowledged Resident 47 did not meet the criteria for antibiotic use according to McGeer's Criteria, so the resident should not have been on ciprofloxacin. LVN 1 stated use of antibiotics exposed the resident to side effects and possible antibiotic resistance bacteria. A review of the facility's policy titled Infection Control, dated 1/2017 indicated it was the policy of the facility to implement an antimicrobial stewardship program which will promote appropriate use of antimicrobials while optimizing the treatment of infections at the same time reducing the possible adverse events associated with antibiotic use. This policy has the potential to limit antimicrobial resistance in the facilities environment. 555780 Page 11 of 13 555780 08/14/2019 Villa Del Rio Gardens 7004 East Gage Avenue Bell Gardens, CA 90201

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain Refrigerator #2 in safe operating condition. Residents Affected - Few This deficient practice placed the foods kept in Refrigerator #2 at increased risk for spoiling and the resident's at increased risk of foodborne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins). Finding: On 08/08/19 at 8:17 a.m., during the initial kitchen tour, Refrigerator # 2 had damaged and torn gasket on the upper edge of the right door. On 08/08/2019 at 8:20 a.m., during an interview, the Assistant Dietary Supervisor (ADS 1) stated the kitchen staff was unaware of the broken gasket and may have missed it during routine cleaning. ADS 1 stated she will notify maintenance immediately to have the refrigerator gasket repaired. A review of facility's policy dated 2018, tilted, Refrigerator and Freezer, indicated to keep refrigerator working efficiently. Periodically, check door gaskets and replace if damaged. 555780 Page 12 of 13 555780 08/14/2019 Villa Del Rio Gardens 7004 East Gage Avenue Bell Gardens, CA 90201

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview, and record review the facility failed to identify risks, and hazards by providing a safe living environment for the resident residing in rooms 70, 72, 76, 77, 78, 79, 81, that had long television (TV) cords, that extended down the wall in to an outlet. This failure had the potential for the residents in rooms 70, 72, 76, 77, 78, 79, and 81 to cause accidents, or to induce harm to themselves. Findings: During the initial tour observation on 08/08/19 at 10:00 a.m., the following resident rooms were equipped with long TV cords, that extended down the wall into an outlet: Resident rooms 70, 72, 76, 77, 78, 79, 81. During a concurrent observation and interview on 08/13/19 at 08:56 a.m. the Maintenance Supervisor acknowledged the resident rooms, 70, 72, 76,77, 78, 79, 81 had a long TV cord, that extended down the wall, into an outlet. Maintenance Supervisor stated the long TV cords are not safe for the residents, especially with the specific population at the facility, and I will speak to the administrator to fix this, make the cords less visible to the residents. A review of the facility's undated policy and procedure titled, Accidents and Supervision, indicated, There resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and as free of accident hazards as is possible; and each resident receives adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s). 555780 Page 13 of 13