OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 2 of 6 sampled residents (#s 1 and 6) who were administered medications. Findings include, but are not limited to: 1. Resident 6 moved into the facility in 05/2010 with diagnoses including hypertension. The resident’s prescribing practitioner orders, dated 12/09/25, and MARs, dated 01/01/26 through 02/02/26, were reviewed and following was identified: Resident 6 had an order for staff to administer a 25 mg tablet of metoprolol (to treat hypertension) once a day. The parameters for the administration of the medication directed staff to “Hold for [systolic blood pressure] less than 100 or [heart rate] less than 60”. * Staff administered the medication eight out of 15 times when it should have been held per parameters. On 02/04/26 at 2:26 pm, Staff 2 (Director of Nursing/LPN) confirmed the medication had not been held per the prescribing practitioner’s orders. The need to ensure medication orders were carried out as prescribed was discussed with Staff 1 (ED) and Staff 2 on 02/04/26 at 2:26 pm. They acknowledged the findings. 2. Resident 1 moved into the facility in 03/2024 and had diagnoses including primary pulmonary hypertension. S/he was identified in the acuity interview as bedbound and receiving hospice services. The resident’s clinical record from 11/02/25 to 02/02/26 was reviewed. The following was identified: a. The resident had an order for losartan, give one tab by mouth every morning for blood pressure. The order instructed staff to hold the medication for a systolic blood pressure of less than 110. Staff administered the medication on one of three occasions when the resident’s systolic blood pressure was less than 110. b. The resident had an order for morphine, give 0.5 ml by mouth every hour as needed for pain or shortness of breath. Staff administered the medication on 01/27/26 at 10:49 pm “to help [him/her] calm down and sleep.” Staff 2 (Director of Nursing/LPN) acknowledged the two medication orders were not administered as prescribed in an interview at 1:58 pm on 02/04/26. The need to ensure medication orders were carried out as prescribed was discussed with Staff 1 (ED) and Staff 2 at 1:58 pm on 02/04/26. They acknowledged the findings.

C303 - Treatment orders 1) MAR of resident's 1& 6 reviewed with med techs. Progress note entered into resident records identyfing the error. Resident MD notified of error. 2) Resident 1 & 6 - Inservice training with all med techs to review proper protocol to ensure parameters for medications are followed as ordered by resident's physician. Resident 1 - Inservice training with all med techs to review proper use of medications as prescribed by physician. Written documentation must reflect purpose of use as prescribed by physician. 3) MAR audit for all current residents will be conducted to identify any medications with paramaters and ensure all medications are administered within parameters as ordered. MAR audit to be conducted weekly. MAR audits to be brought forward to QAPI x 3 months or until compliance is achieved. 4) DON will be responsible to ensure inservice training is completed and corrections are made. DON and Executive Director will be responsible to ensure ongoing monitoring is completed.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by:

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents' MARs included resident-specific parameters and instructions for PRN medications for 3 of 6 sampled residents (#s 1, 2 and 3) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 01/2024 with diagnoses including chronic (diastolic) heart failure and acute respiratory failure. S/he was identified in the acuity interview as receiving hospice services. Resident 3's MARs from 01/01/26 through 02/02/26 and physician orders were reviewed, and revealed the following PRN medications lacked resident-specific parameters including sequential order of use: * Acetaminophen 325mg (for pain); * Lidocaine 4% patch (for pain); * Morphine 20mg/ml (for pain and shortness of breath); * Bisacodyl 10mg rectal suppository (for constipation); * Fleet enema (for constipation); * Lactulose 10gm/15ml (for constipation); * Milk of Magnesia 400mg/5ml (for constipation); * Miralax Powder (for constipation); * Ipratropium/Albuterol 0.5-2.5mg (for shortness of breath); and * Oxygen via nasal cannula (for shortness of breath). The need to ensure MARs were accurate and provided resident-specific parameters and instructions for PRN medications was reviewed with Staff 1 (ED) and Staff 2 (Director of Nursing/LPN) on 02/05/26 at 10:29 am. They acknowledged the findings. 2. Resident 2 moved into the facility in 10/2022 with diagnoses including breast cancer and chronic pain. The resident’s MARs, dated 01/01/26 through 02/02/26, were reviewed and the following was identified: a. The following PRN medications lacked the sequential order for administration: * Acetaminophen (for mild to moderate pain); and * Tramadol (for pain management). b. The following PRN medication lacked resident-specific parameters and instructions: * Acetaminophen (for elevated temperature). The need to ensure MARs were accurate and included resident-specific parameters for PRN medications used for the same diagnosis was discussed with Staff 1 (ED), Staff 2 (Director of Nursing/LPN), on 02/05/26 at 10:05 am. They acknowledged findings. 3. Resident 1 moved into the facility in 03/2024 and had diagnoses including left hip fracture with repair. S/he was identified in the acuity interview as bedbound and receiving hospice services. The resident’s clinical record from 11/02/25 to 02/02/26 was reviewed. The resident had the following orders: *Bisacodyl, insert one suppository rectally every day as needed for constipation; and *Polyethylene glycol (PEG) powder, dissolve 17 grams in four to eight ounces of liquid and drink by mouth every day as needed for constipation. Bisacodyl was administered by staff on 01/20/26 and 01/21/26, and the PEG powder was administered on 01/20/26 and 01/30/26. There were no written instructions for staff regarding which bowel medication to administer first. In an interview on 02/02/26 at 2:16 pm, Staff 6 (MA) confirmed the lack of parameters for the bowel medications. The need to ensure resident-specific parameters and instructions for PRN medications was discussed with Staff 1 (ED) and Staff 2 (Director of Nursing/LPN) at 1:58 pm on 02/04/26. They acknowledged the findings.

C310 - Medication Administration 1) MAR for residents 1, 2, and 3 will be updated with signed physician orders to include parameters for administration including sequential order of use for PRN oxygen, pain medications, and bowel medications. 2) Inservice training will be completed by DON with LNs, RCCs, and Med Techs to ensure that all new PRN orders include required parameters and sequential order of use at time of confirmation. 3) Medication orders will be monitored daily through the triple check and order confirmation process and 3x/wk clinical meetings. MAR audits will be brought forward to monthly QAPI for review. 4) DON and Executive Director will be responsible to ensure corrections are completed and monitored.

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by:

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications had written, resident-specific parameters and documentation that non-pharmacological interventions were tried with ineffective results prior to administering them for 1 of 2 sampled residents (#1) who had orders for PRN psychotropic medications. Findings include, but are not limited to: Resident 1 moved into the facility in 03/2024 and had diagnoses including left hip fracture with repair. S/he was identified in the acuity interview as bedbound and receiving hospice services. The resident’s clinical record from 11/02/25 to 02/02/26. The following was identified: a. The resident had orders for haloperidol, give 0.25 ml by mouth every six hours as needed for restlessness/anxiety and lorazepam, give 0.25 ml by mouth/under tongue every four hours as needed for anxiety/agitation/restlessness. Haloperidol was administered seven times between 01/12/26 and 01/27/26. Lorazepam was administered five times between 01/25/26 and 01/27/26. There were no documented resident-specific parameters as to how the resident displayed the above behaviors and which medication to administer first. There was no documented evidence staff attempted non-pharmacological interventions with ineffective results prior to administering the medication. b. The resident’s lorazepam order was updated on 01/27/26 to give 0.25 ml every four hours as needed for anxiousness or restlessness. There were no documented resident-specific parameters as to how the resident displayed anxiousness or restlessness, and there was no documented evidence staff attempted non-pharmacological interventions with ineffective results prior to administering the medication. In interviews at 2:16 pm and 2:39 pm, respectively, on 02/02/26, Staff 6 (MA) and Staff 16 (MA) confirmed the lack of non-pharmacological interventions for the two PRN medications. The need to ensure PRN psychotropic medications had written, resident-specific parameters and documentation that non-pharmacological interventions were tried with ineffective results prior to administering them was discussed with Staff 1 (ED) and Staff 2 (Director of Nursing/LPN) at 1:58 pm on 02/04/26. They acknowledged the findings.

C330 - Psychotropic Medication 1) MAR for resident 1 will be updated to include written resident specific non-pharmacological interventions are tried prior to administration of PRN psychotropic medications. Parameters must include sequential order of use if more than one PRN psychotropic medication is ordered. Documentation must also include how resident displays behaviors warranting administration of PRN psychotropic medications. 2) Inservice training will be completed by DON with LNs, RCCs, and Med Techs to ensure all new PRN pscyhotropic orders include non-pharmacological interventions and sequential order of use if more than one, as well as documentation of behaviors warranting PRN psychotropic administration. Examples of resident behaviors will also be documented on resident service plan and/or TSP. 3) Psychotropic medications will be monitored daily through the triple check and order confirmation process and 3x/wk clinical meetings. Psychotropic audits will be brought forward to monthly QAPI for review. 4) DON and Executive Director will be responsible to ensure corrections are completed and monitored.

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. This Rule is not met as evidenced by:

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure fire drills conducted included all the required components in accordance with the Oregon Fire Code. Findings include, but are not limited to: Fire and life safety records between 08/2025 and 01/2026 were reviewed and revealed the following: Fire drills conducted were lacking the following required components: * Escape route used; * Problems encountered, comments relating to residents who resisted or failed to participate in the drills; * Number of occupants evacuated; and * Evidence alternate routes were used. The need to ensure fire drills included all required components were addressed and documented for each fire drill was discussed with Staff 1 (ED) on 02/04/26 at 11:40 am. She acknowledged the findings.

C420 1) Executive Director will review Fire Drill documentation requirements with Plant Operations Director and designees who conduct facility fire drills. Documentation requirements will include required components: *Escape route used *Problems encountered *Comments related to residents who resisted or failed to participate in drills *Number of occupants evacuated, and *Evidence alternate routes were used. 2) Fire Drills will be conducted with ED or Sr. ED to ensure drill contains all compenents and documentation required by regulation x 3 months or until corrected. 3) Documentation of drill will be provided to ED and Sr. ED within 24 hours of drill for review and to ensure all required documentation componants are completed per regulation. Fire Drill documentation will be brought forward to monthly QAPI for review. 4) Plant Operations Director, Executive Director, and Sr. Executive Director will be responsible to ensure corrections are completed.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by:

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. An ALF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g. floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the interior was kept clean and in good repair. Findings include but are not limited to: The interior of the facility was toured on 02/02/26 at 9:21 am, and the following was identified: * Carpets throughout the facility were in need of cleaning, including outside multiple resident apartments on the first floor, inside of apartment #203, outside of the medication room, and a resident use stairway across from apartment #246; * Insects and debris were observed in light fixtures throughout the facility; * There were multiple areas in a resident use laundry room located on the first floor: * The threshold strip was missing; * The linoleum flooring had gouges observed in front of the first dryer and was in disrepair in front of the second washing machine; * There were holes in the wall to the right of the utility sink; * The utility sink had brown and black matter inside of the basin and a piece of the top rim of the sink was chipped off; * The baseboard located under the light switch was peeling off the wall; * There were drips observed down the wall prior to entering the laundry room and inside of the laundry room; * The blinds located on Hall A, in back activity and sitting area, was missing the tilt wand; * The blinds located to the right of apartment #211 on B Hall were in disrepair; and * The zipper holding the upholstery together on the love seat located across from the reception desk was in disrepair thus exposing the foam underneath deeming it an uncleanable surface. A tour of the interior facility was completed with Staff 1 (ED) and Staff 4 (Plant Operations Director) on 02/03/26 at 10:48 am. They acknowledged the findings.

C613 - General Building cleanliness/repair 1) Carpet cleaning for Royal Anne will be occur on a rotating quarterly basis for all common areas and PRN. Cleanings will be completed outside of first floor apartments, inside apartment #203, outside of medication room, and resident stairway across from apartment #246. Insects and debris will be cleaned from common area light fixtures on 1st and 2nd floors. Resident laundry room repairs will include: *Replacement of flooring threshold strip *Replacement of vinyl flooring *Repair of holes in walls *Cleaning or replacement of utility sink *Repair of baseboard *Cleaning of walls entering laundry room Blinds at end of A Hall and outside of RA #211 will be replaced. Tilt wand will be replaced in A Hall sitting area. Zipper of love seat in lobby sitting area will be repaired or new cushion provided if unable to be repaired. 2) Inservice training will be completed with facility staff on how to enter work orders into TELs tracking system for repairs and replacments needed. 3) Quarterly environmental walk through will be completed by Plants Ops Director or designee and E.D or Sr E.D to ensure ongoing compliance and cleanliness. Audit results will be brought forward to QAPI for review. 4) Plant Operations Director, Executive Director, and Sr. Executive Director will be responsible to ensure completion and monitoring.

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. An ALF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g. floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair. This Rule is not met as evidenced by: