**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Record review of Resident #11's admission record dated 10/25/23 documented a [AGE] year-old female admitted to the facility on [DATE] and discharged on 09/20/23. The form further documented Resident #11 with diagnoses including, unspecified dementia (a group of thinking and social symptoms that interfere with daily functioning), muscle wasting and atrophy (a decrease of muscle mass and strength), age-related physical debility (group of symptoms related to age that cause frailty), lack of coordination (group of symptoms that cause impaired direction) , and unspecified hearing loss (inability to hear). Resident #11 was not identified as her own responsible party. Record review of Resident #11's quarterly minimum data set (MDS) revealed a BIMS score of 99 indicating severe cognitive impairment. It further documented Resident #11 required a walker for mobility and required supervision when walking up to 10 feet. The MDS documented, Resident #11 did not use a wander/elopement alarm. Furthermore, the form documented a 0 when asked Has the resident wandered?, indicating the behavior had not been exhibited. Record review of Resident #11's comprehensive care plan documented Resident #11 was an elopement risk/wanderer related to attempts to leave facility unattended with an initiated date of 09/19/23. Resident #11's care plan stated The resident's safety will be maintained through the review date and the resident will not leave the facility unattended through the review date with a revision date of 09/26/23. Interventions included, 09/19/23 elope from facility, door codes changed, 1:1 monitoring, moved to room closer to nurse station, wander guard, alarms checked and functional, critical behavior monitoring, will be transferred to secured unit upon bed availability .complete wandering evaluation tool .identify pattern of wandering . All with initiation date of 09/19/23. Record review of Resident #11 physician order revealed an order to verify function of wander guard daily and wander guard in place .verify placement every shift for elopement with a start date of 09/20/23 and that was discontinued with no end date noted. Record review of Resident #11 September 2023 licensed nurse administration record dated 10/26/23 revealed order had been completed and documented for every shift on 09/20/23 as ordered. Record review of Resident #11 Wandering Evaluation completed upon admission on [DATE] at 08:23 a.m., documented a summary of finding score of four (4) indicating resident was a low risk for wandering. Resident #11 was not a wandering risk at that time. Record review of Resident #11 wandering re-evaluation completed on 09/19/23 at 10:30 a.m. documented a summary of findings score of five (5) indicating resident was a low risk for wandering. Furthermore, document recorded Resident #11 was a wandering risk and interventions and care plans had been re-evaluated Record review of Resident #11 progress notes with an effective date 09/19/23 at 12:24 p.m. and written by Staff M revealed a CNA last saw Resident #11 at approximately 09:00 a.m. Record review of Resident #11's progress notes signed and dated 09/19/23 at 12:50 p.m. by Staff J quoted in part, family in to see Resident #11 at 10:30 a.m., Staff E assisted family with locating resident. Resident #11 not found in facility. Facility conducted 100% of room search in the facility. Resident was last seen in facility by Staff L at around 09:00 a.m. Staff began to search for Resident #11inside and outside facility, restaurants, gas stations, stores, and surrounding neighborhoods; however Resident #11 was not located anywhere. Local police department notified at approximately 11:00 a.m. DON spoke to Officer regarding details describing Resident #11's last whereabouts and clothing worn. At approximately 11:30 a.m., Resident #11 was located by local police department walking on a street. Resident #11 was brought back to facility. Physician and family were made aware. Record review of Resident #11 Change of condition communication form dated 09/23 at 12:47 p.m. revealed the change in conditions, symptoms or signs to report: Pt (patient) had incident of elopement .this started on 09/19/23 . Nurse suggestion .Transfer to the hospital. Record review of Resident #11's weekly skin evaluation signed and dated 09/19/23 at 12:59 p.m. revealed resident did not have any abnormal skin areas i.e., bruises, skin tears, pressure ulcers, non-pressure wounds etc. Record review of Resident #11's pain evaluation signed and dated 09/19/23 at 12:59 p.m. revealed resident had no pain upon return to facility on 09/19/23. Record review of Resident #11 progress notes with an effective date of 09/19/23 at 13:20 p.m. and written by Staff J quoted in part, Resident was returned to facility by PD at approximately 1200 p.m. Resident is alert and oriented x 2. Patient denies pain at this time. Head to toe assessment conducted, no bumps or lesions noted to head .doctor, new order received: transfer resident to DHR ER for evaluate and treat. FM A in facility and aware and in agreement. Record review of Resident #11 progress notes with an effective date of 09/19/23 at 13:35 p.m. and written by Staff J, quoted in part, EMS in facility to transport resident to ER, family at bedside. Resident is calm and cooperative. Resident exited the facility at approximately 1330. Report called in by Staff E to ER staff. Record review of Resident #11 progress notes with an effective date of 09/19/23 at 20:42 p.m., quoted in part, Resident arrived from [hospital] awake, alert and VWNL (vital signs within normal limits) denies any pain or discomfort N/O (new orders) Keflex (antibiotic) 500 (milligram) capsule give 1 cap (capsule) QID (four times a day) x 5 (times five) days. Order carried out. Initial dose given no adverse reactions noted. Record review of Resident #11 progress notes with an effective date of 09/19/23 at 06:03 a.m., quoted in part, Resident slept well during the night continues. 1:1. Record review of Resident #11 progress notes with an effective date of 09/20/23 at 10:46 a.m., quoted in part, Resident in room talking on the phone with a family member. 1:1 aide at bedside. Patient calm and cooperative. Wander guard in place to left wrist. Will continue to monitor. Record review of TULIP (HHSC online incident reporting application on 10/24/23 at 09:00 a.m. revealed the facility made a self-reported incident on 09/19/23 at 10:30 a.m. regarding Resident #11's elopement. Record review of the facility map and evacuation routes, revealed a total of nine (9) exits were identified as exit doors. Initial rounds were conducted on 10/24/23 beginning at 11:00 a.m. throughout the facility. The facility was well lit, temperature was comfortable, and staff were seen appropriately interacting and assisting residents in their rooms and in the hallways. The facility was clean, well-lit, the ambient was comfortable with comfortable temperature and noise level. Resident rooms were clean, orderly, without any noted hazards or clutter. There were no sounds of yelling, screaming, or moaning. Residents in bed had their call lights within their reach. Call lights were observed activated and timely answered. Nurses were administering care and medications in a timely manner. Water and belongings were observed at the bedside of the residents and within their reach. No resident was observed to display any disrupting or aggressive behaviors. No injuries or bruising was noted on any resident that would raise suspicion of abuse or neglect. There were no active cases of COVID-19 positive residents in the building. Visitors were observed entering and exiting through the main entrance after being allowed entrance. Residents in designated smoking area being observed monitored. Other exit doors locked and secured with codes and screech alarm. Observation on 10/24/23 at 11:00 a.m. of the surrounding streets revealed a highly trafficked four lane road with a center lane and a speed limit of 40 miles per hour. In a telephone interview with FM A on 10/26/23 at 08:10 a.m. revealed she and an unnamed family member came to visit Resident #11 on 09/19/23. FM A stated she arrived at the facility at 09:55 a.m. and went straight to Resident #11's room. FM A stated after she did not find Resident #11 in her room, she decided to look in the room she was previously assigned to because she had been moved the day before. FM A stated again she could not find Resident #11. FM A stated she then decided to look in other areas of the facility including the activities area, designated smoking area, therapy, and the lounge. FM A stated that once she eliminated the areas where she believed Resident #11 could be, she then asked the staff for the whereabouts of Resident #11. FM A stated a staff member stated she was in the shower. FM A stated she decided to wait until Resident #11 came out from the shower, but after 20 minutes had gone by and Resident #11 did not come out from the shower, she inquired again to staff about the whereabouts of Resident #11. FM A stated staff then became involved in searching for Resident #11 all around the facility and police were called to assist in the search. FM A stated Resident #11 was found approximately two (2) hours after she initially arrived at the facility. FM A stated Resident #11 was brought back to the facility and then transferred to the emergency room for further evaluation. FM A stated Resident #11 mentioned she was upset about the room change the previous night, not being able to sleep and walking out the front door because she wanted to leave. FM A stated after she came back to the facility from the hospital, staff informed her Resident #11 would be transferred to a different nursing facility for safety. In an interview on 10/26/23 at 11:15 am, with CNA L stated exit doors were secured with codes and alarms. CNA L stated residents and visitors did not have codes to the exit doors. CNA L stated the facility did have a designated smoking area where residents are able to go outside supervised. CNA L stated she last saw Resident #11 in her room after breakfast. CNA L stated Resident #11 went to restroom in her room and after briefly sitting on her bed she laid down. CNA L stated Resident #11 had mentioned to her that she had not slept the night before. CNA L stated Resident #11 was last seen at approximately 09:30 a.m. that morning wearing a pink sweater, brown blouse, and beige pants CNA L stated she did not see Resident #11 anymore and did not know her whereabouts until family came to ask for her at approximately 09:45 a.m. CNA L stated all staff went to look in every room, outside, rehab, activities room, parking area, and in the surrounding areas. Staff L stated she did not know what time, the location, who found Resident #11 and how she was brought back to the facility. In an interview on 10/26/23 at 11:25 a.m., CNA J stated exit doors were secured with alarms that could be turned off by punching in a code. CNA J stated residents were allowed to go outside of the facility supervised to designated areas such as the smoking area. CNA J stated she was assigned to work shower duties the day Resident #11 was missing. CNA J stated Resident #11 had not showered and that Resident #11 had just been transferred from hall 200 to room [ROOM NUMBER]-A in hall 300. CNA J stated she was on break when FM A arrived at facility and search for Resident #11 was initiated. CN J stated residents were accounted for when doing walking rounds in the morning, as they are passing breakfast trays, when they round every two (2) hours. CNA J stated she does not know where Resident #11 was found or when. Staff J stated Resident #11 was brought back to the facility by police, she was taken to the hospital and when she came back she was put on 1:1 observation. In an interview on 10/26/23 at 11:35 a.m. with LVN K stated he worked on hall 300 for approximately twelve (12) years as a floor nurse. LVN K stated he was not working the day of the incident; however, exit doors are secured by a code and an alarm with a 15 second delayed egress and a stop alarm (screech annunciator). LVN K stated that residents must ask staff for assistance to go outside in the assigned patio area. In an interview on 10/26/23 at 12:10 p.m. with LVN E stated she had worked at facility for approximately three (3) yeaars as a floor nurse. LVN E stated exit doors are secured with a code and an alarm with a 10 second delay and stop alarm. LVN E stated residents were not allowed to go outside unsupervised unless with staff or family member and depending on the resident's independent need. LVN E stated her shift on 09/19/23 started at 02:30 a.m. to assist a co-worker and was assigned to hall 300 including, Resident #11. LVN E stated Resident #11 was moved from 200 to hall 300 the day before. LVN E stated Resident #11 was not completely comfortable in her room and that Resident #11 spend her time at the nurse's station. LVN E stated Resident #11 was a smoker and had wanted to go outside. Staff E stated Resident #11 needed to wait for someone to assist her. LVN E stated her shift changed at 06:00 a.m. and her assignment changed to a different hall including the resident she was taking care of. LVN E stated she observed Resident #11 sitting at the nurse's station at approximately 08:40 a.m. LVN E stated Resident E went to her room to change her shirt because it was stained and returned to the bistro area around 08:50 a.m. wearing a blue shirt. LVN E stated family came to visit Resident #11 close to 10:00 a.m. LVN E stated she was approached by her supervisor and was asked the whereabouts of Resident #11. LVN E stated she assisted in searching for Resident #11 in the activities area, bistro, and smoking area. LVN E stated she knew Resident #11 was missing when Resident #11 could not be located in those areas. LVN E stated after code elopement was announced, she and other staff were assigned to look in all halls, restrooms, closets, locked and unlocked doors, in halls, outside parking lots, staff searched in each direction of the facility, drove in the surrounding areas of the facility. LVN E stated family and staff called Resident #11's cell phone multiple times and went unanswered or went to voicemail. LVN E stated Resident was found at approximately 11:30 a.m. on [NAME] Rd. in Edinburg and brought back to the facility by police. LVN E stated she performed a head-to-toe assessment immediately. LVN E mentioned no injuries were noted. LVN E stated Resident #11 was sent to hospital for further evaluation and treatment, an incident report was made, and in-service of staff was performed. In an interview on 10/26/23 at 04:45 p.m., LVN D mentioned she has been employed at the facility for seventeen (17) years. LVN D stated she makes sure all residents are accounted for in the facility by performing a walking round on the hall she is assigned and count the residents to assure they are in the facility. LVN D stated staff should round on residents every two (2) hours or more often if needed. LVN D stated exit doors have a code. LVN D also mentioned residents should not know the code, and that if administration finds out residents know the codes, administration will change the codes frequently. She stated the exit codes were changed within the last week. In an interview on 10/27/23 at 08:45 a.m., BOM U stated she had been employed at facility for approximately twenty-four (24) years. BOM U stated she was assigned to the reception area and her responsibilities included allowing entry and exit to visitors, staff and/or residents to the facility. BOM U stated visitors no longer have to sign in or out. BOM U stated visitors nor residents have entrance or exit codes. BOM U stated some residents were able to obtain codes because they watched staff punch the codes on the access keypad of the exit doors as they exited or entered the facility. BOM U stated exit doors have a code that must be punched in a keypad in order for the door to unlock and allow the person to enter or exit. BOM U stated emergency exit doors have a push bar that is equipped with a 15 second delayed egress and a stop alarm (screech annunciator). BOM U stated she accounts for residents by obtaining a printed report from admissions department. She stated she looked at the schedule to make sure all residents are in the facility and checks with the nurses if they are not. BOM U stated if she found a missing resident she would inform admissions and checked to see if the resident was at the facility. BOM U stated she has access to the computer where she could see resident pictures to identify the residents. BOM U stated the facility discouraged staff from sharing codes with other employees, staff, and visitors. In an interview on 10/27/23 at 11:05 a.m., Resident #12 stated staff treated him well. Resident #12 stated he was happy with the services he was receiving at facility. Resident #12 denied pain or discomfort. Resident #12 stated staff brought him his medication on time. Resident #12 stated the doors have alarms and he cannot go out the exit doors. Resident #12 stated he needed to ask staff for assistance to go outside. In an interview on 10/27/23 at 11:15 a.m.Resident #13 stated staff treated her well. Resident #13 stated she was happy with the services provided by the facility. Resident #13 stated she was comfortable and denied pain. Resident #13 stated staff brought her medication on time. Resident #13 stated she knows how to make complaints and to who in the facility to make them to. Resident #13 stated she is mostly in bed and does not usually go outside. In an interview on 10/27/23 at 11:30 a.m., Resident #14 stated he was happy with the services he was receiving at the facility. Resident #14 stated he did not feel threatened and had not been hurt by staff. Resident #14 denied pain and stated he was comfortable. Resident #14 stated he went outside with the assistance of staff and did not know the codes to the doors. In a telephone interview on 10/27/23 at 02:00 p.m., ADON C stated he had been employed with the facility for approximately 2 years. Staff C stated he accounted for residents by rounding in the morning. ADON C stated if a resident was out on pass, on an appointment or not in his/her room he would communicate with other staff to find out the whereabouts of the resident. ADON C stated medical records took a picture of the resident and uploaded it into the resident profile. ADON C stated everyone who had access to resident records had access to view the resident profile and was able to identify residents. ADON C stated the front door was always locked and staff did not allow residents to go through the front door unsupervised. ADON C stated only employees know the codes in order to deactivate the alarms to the doors. ADON C stated doors are secured by a magnet punch code to be unlocked and codes are not shared with visitors and residents. ADON C stated only management had access to door codes. ADON C mentioned employees, nurses and charge nurses do not have access to door codes. ADON C stated staff would notify management when door is opened without an alarm going off. ADON C stated there is one code for all staff members. ADON C stated if a resident is missing he would notify the charge nurse immediately and ask other staff including CNA and LVN about the whereabouts of the resident. ADON C stated that the process is usually immediately, but following the identification of a missing resident, the charge nurse and management team including the DON and the administrator would be notified. ADON C stated an onsite search would be conducted for the resident. ADON C stated an emergency code purple to all staff would be announced to indicate a missing resident. ADON C stated staff would search every door, closet, room, parking area would be searched, and the police would be called. ADON C stated this process usually is less than ten (10) minutes because all staff is assigned to a hall and the facility would know immediately whether the resident was within the facility. ADON C stated facility would then designate a staff member as the point of contact who would communicate to others of all updates. ADON C stated that meanwhile, the remaining facility staff would continue with the search on the outside of the facility. ADON C stated after code purple was initiated, the police department was called immediately, the family of the resident would be updated, and the physician would be notified within one (1) hour. ADON C stated that once the resident was found, code purple would be called off, a head-to-toe assessment would be performed, the physician and family would be updated. ADON C mentioned code purple or elopement incidents are self-reported incidents. He stated the facility would perform an in-service for the staff on elopement and the exit door codes would be changed. ADON C stated that facility staff performed an elopement risk assessment on admission to assess residents for risk of eloping. He stated that those residents who were high risk of elopement are moved closer to the nurse's station and the staff would maintain a closer observation to those residents. ADON C stated the facility was not a lockdown facility meaning the facility did not have a secure memory care unit. ADON C stated staff increased rounding on residents with high-risk elopement risk. He stated he had not observed cameras on the inside of the facility premises and only had observed a few on the outside. ADON C stated facility offers in-services weekly on different topics including abuse, neglect, and exploitation. In an interview on 10/27/23 at 02:00 p.m., DON stated she had worked at the facility for four (4 years) and was responsible for in-servicing staff, oversight of floor staff and reporting to the administrator. DON stated certified nurse assistants (CNAs) round every two (2) to three (3) hours and as needed. She stated nurse's round at the beginning of their shift, during medication pass and at the end of their shift. DON stated that information is passed on report when a resident is out on pass and that a resident must be signed out if they do go on pass. DON stated if a resident is missing staff must go room to room, in the activity's areas, or in rehab to ensure residents are not in the facility. DON stated the resident roster is compared to each hallway to make sure all residents are accounted for. Staff A stated that if a resident is identified as missing, a code is announced to alert all staff of the missing resident. DON continued by stating that staff then are assigned to search in all areas of the facility. DON stated if the resident is not located within the facility, staff are assigned to go out of the premises in teams to search for the resident within a 3-mile radius in all directions. DON stated the police department, family and physician is then notified of the resident's elopement. DON stated that no more than 10 minutes of identifying a missing resident is a code for elopement activated and police are notified. DON stated facility exit doors are secured by alarms that must be deactivated with a code that was entered on a punch keypad. DON stated those codes are not shared with residents or visitors. DON stated the facility has identified residents who figure the codes out by observing staff members while entering the code on the keypad. DON stated that the facility prevents residents from accessing the codes by frequently changing the codes, changing them once the code has been breached or as often as needed. DON stated the facility prevents residents from entering/leaving the facility by assigning two receptionists between the hours of 08:00 a.m. and 08:00 p.m. DON stated after these hours, visitors must ring the doorbell, so the door is opened by a staff member at the nurse's station. DON stated the receptionists have access to the resident pictures that are on the resident profile and receptionists can identify residents who attempt to exit the front door unsupervised. DON stated Resident #11's family members arrived to visit with Resident on 09/19/23 and at approximately 10:30 a.m. approached LVN E to assist in locating resident within the facility. Staff A stated family and LVN E were not able to locate Resident #11 after searching on the premises themselves and delayed informing other staff of the resident's status because Resident #11 had not ever voiced desires to go home and had never had exit seeking behaviors. DON stated FM A and Staff E notified other staff members of the management at approximately 10:45. DON stated the facility activated the code for elopement at approximately 11:00 a.m. when police were notified. DON stated Resident #11 was located by local police department at 11:30 a.m., approximately two (2) miles from the facility. DON stated Resident #11 walked to a nearby hospital where she asked a woman (unknown name) for a ride to a local restaurant. DON stated Resident #11 stayed to have a drink at the restaurant and then walked home. DON stated Resident #11 knows the address to her apartment. DON stated Resident #11 was found walking with herself using her walker on [NAME] Road in the direction of her apartment. DON stated local police department brought Resident #11 back to the facility. DON stated staff performed a head-to-toe assessment, food and water was offered, and the physician was notified. DON stated Resident #11 was interviewed, and it was revealed she left through the front exit. DON stated she was unaware if Resident #11 piggybacked (walked out) with a group of other visitors or if Resident #11 held the door for 15 seconds so the alarm would not sound. DON stated that the facility was in-servicing staff and performing routine mock drills in order to better prepare staff and prevent a future elopement. DON stated the facility was also changing exit door codes frequently and incoming residents were screened to make sure their needs could be properly addressed. DON stated incoming residents with high score risk elopement risks would be placed on 1:1 until the facility was able to transfer them to a facility that could accommodate their needs. In an interview on 10/30/23 at 09:55 a.m., Resident #15 in room stated she was happy with the services received at the facility. Resident #15 stated she does not feel threatened and was not hurt by facility staff. Resident #15 stated she did not always like the food; however, she knew how to file a complaint to the Administrator regarding her concerns. Resident #15 stated staff brought her medication on time. Resident #15 stated she did not know the codes to the exit doors, staff did want to share the codes with her, and that the doors had alarms. Resident #15 stated staff assist her if needing to go outside. In an interview on 10/30/23 at 10:05 am, Administrator stated she had been employed by the facility for two (2) years and was responsible for the administrative duties of the facility. Stated she was also responsible for performing in-services on staff as well as DON and ADON C. Administrator stated topics of in-services provided to staff resident supervision, Stated best practice is for CNAs and nurses to round the assigned hallways when they start their shift, every two (2) hours and as needed. Nurses round when they start their shift, every two (2) hours and as needed on their assigned hallways. Administrator stated residents are accounted for in the facility by staff communicating during report and walking rounds. Stated exit doors are secured by maglocks (magnetic lock which is a locking mechanism that uses an electromagnetic field controlled by an electrical system that can be configured with a switch, keycard reader or biometric scanner) and a code that releases the maglock. Administrator stated the exit doors are also secured with a fifteen (15) second delayed egress and a stop alarm (screech annunciator). Stated exit door codes are changed monthly or as needed and are not shared with visitors or residents. Administrator stated the facility prevented visitors and residents from accessing the codes by offering in-services to staff on not sharing codes. Stated residents have accessed the codes before by watching staff members input the code as they are entering or exiting the facility. Administrator stated facility changed exit door codes as soon as facility identified a code had been breached and resident or visitor had learned or accessed a code. Stated facility had no working cameras at the exit doors. Administrator stated on 09/19/23 Resident #11's family member came to visit her. Stated floor staff notified her that Resident #11 was missing. Administrator stated the facility initiated their code purple (elopement protocol) immediately and followed their procedures. Adiminstrator stated they assigned a point of contact and assigned teams to search within the facility and outside of the facility. Stated that staff searched a radius of 1 mile in each direction of the facility. Staff B stated the police and physician were notified. Stated Resident #11 had been previously assessed and was not an exit seeker and never verbalized or gave any indication of wanting to leave. Administrator stated Resident #11 was found by local police department and returned to the facility unharmed. Stated a head-to-toe, pain, and skin assessment was performed upon Resident #11's return. Administrator stated family was at the facility, but physician was informed. Stated upon Resident #11's return, staff were in-serviced on elopement, a head count was performed on all residents, a secured clear box was placed over alarm over front door to prevent people from unplugging the maglock and deactivating it. Administrator stated facility prevented a reoccurrence of this incident by performing mock drills, changing exit door codes frequently, maintaining communication with staff regarding whereabouts of residents, and in-servicing staff on elopement. Interview on 11/01/2023 at 2:00 p.m., The Administrator said they change the code monthly or as needed. She said if they find out the codes have been compromised, they will change it immediately. Record review of maintenance logbook documentation stating Year 2023 Codes doors marked each exit tested for months April through October. Record review of facility in-service training report revealed facility had a training with staff including nursing staff, social worker, administrative/office, food service and maintenance personnel over Elopement and Wandering Residents on 09/19/23. Record review of facility in-service training report revealed facility had a training with staff including nursing staff, social worker, administrative/office, food service and maintenance personnel over Abuse and Neglect/Resident Supervision, Answer Call lights in a timely manner on 09/19/23 with the following evaluations, comments, suggestions: Elopement process: follow proper protocol for elopement events: Meet nurses' station, search all areas of facility, search all areas outside, search does not end until patient is found, ensure codes are changed, monitor as needed for safety of residents. Record review of facility in-service training report revealed facility had an elopement mock drill with staff including nursing staff, social worker, administrative/office, food service and maintenance personnel on 09/22/23 with the following contents or summary of training session: follow proper elopement protocols, exit door codes changed monthly or as needed, supervise residents that exhibit exit seeking behaviors, monitor for exit seeking behaviors/contact family if behaviors are exhibited. Record review of facility in-service training report revealed facility had an elopement mock drill with staff including nursing staff, social worker, administrative/office, food service and maintenance personnel on 09/25/23 with the following contents or summary of training session: follow proper elopement protocol, codes for exit doors will be changed monthly [TRUNCATED]