The resident, identified in inspection records as R1, had scored eight out of 15 on a cognitive assessment in May, indicating moderate impairment.
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Staff searched the building before finding her at the gas station across the street.
The resident, identified in inspection records only by age and sex, was admitted on August 5, 2025.
The resident at Claremont Care Center had been admitted with a history of falling and a fractured right thigh bone that required surgical repair.
The violations occurred during wound treatments for two residents with serious injuries requiring enhanced infection control precautions.
The nurse acknowledged this created serious safety risks.
CNA HH told inspectors she was "unaware of any of the residents in the room being on EBP" and had been providing care without protective equipment for weeks.
The resident suffered a fracture at the superior endplate of her L1 vertebra after her wheelchair flipped backwards during transport from dialysis on April 25.
The resident, admitted June 19 with spinal stenosis and recent lumbar spine fusion, was ordered to see a neurologist on June 24 for post-surgical follow-up.
R350 arrived at the facility with existing pressure injuries — a full-thickness stage 3 ulcer on the right buttock and a stage 1 injury on the left heel.
Licensed Vocational Nurse 3 acknowledged receiving the lorazepam order on March 23 but admitted missing the step of ensuring informed consent.
She had already given morning medications to ten residents but waited hours to sign the electronic records, using someone else's login credentials to do it.