Based on clinical record review, staff interview, family interview, and the chief of police interview, the facility failed to provide a safe discharge for a resident newly admitted from the emergency room (ED) to the facility on 6/6/23 after sustaining a fall at work which resulted in a fractured right cuboid bone and calcaneal fracture (ankle). Staff received a verbal telephone order okaying the admission of this resident. The facility accepted the resident into the facility, began the admission process, assisted the resident to a room, provided toilet use assistance, and performed a skin assessment of the gluteal area. The facility performed 2 Covid tests on the resident; a positive test result was received and the facility informed the resident they could not meet her needs due to the positive test. The facility transferred the resident into a bariatric wheelchair and placed the resident outside on a sidewalk with a bedside commode and walker to await transport to home. The facility failed to follow proper notices and documentation for an involuntary discharge for one (1) resident therefore causing an Immediate Jeopardy to the health, safety, and security of the resident (Resident #1). The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of July 28, 2023. The Facility Staff removed the Immediate Jeopardy on July 28, 2023 through the following actions: a. Assurance that all necessary staff had been educated on the admission and Discharge policy. The scope lowered from a J to G at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility identified a census of 94 residents. Findings include: An X-ray report from a local hospital for Resident #1 dated 6.6.23 at 7:54 a.m. included the following: a. A mildly comminuted cuboid fracture. b. A mildly displaced fracture of the anterior process of the calcaneus. A Discharge Instructions form from the hospital dated 6.6.23 at 9:07 a.m. indicated the resident's diagnoses included: heel pain, morbid obesity, and a right foot injury. The physician orders included the following: a. Keep foot elevated for decreased swelling and pain. b. Non-weight bearing on the foot with the use of a walker. During an interview 7.26.23 at 1:22 p.m. a family member indicated the resident fell as she went into work on 6.6.23. The resident drove herself to the local ED and called this family member. Staff in the ED treated and released the resident. After the ED staff positioned the resident in the family member's car without a crutch, walker, or wheel chair (w/c) and with a directive of a non-weight bearing status, the ED staff directed the family and resident to go home. Family drove the resident to the local long term care equipment company in town and attempted to purchase/rent bariatric adaptive equipment such as a walker and a wheelchair but the equipment had not been in stock so they ordered the items. At that point the family knew they could not care for the resident at home due to her size and no adaptive equipment so they drove to the local nursing facility. The family members left the resident in the car and went into the facility and asked if the facility staff could rehab her to home. The family and Staff A, CNA/Community Development Director went out to the car when Staff A stated absolutely they could have admitted the resident to the facility for care and services. The staff member then took the resident inside of the facility and began the intake paperwork. Then staff took the resident into what would have been her room, performed an exam, rearranged the room, and performed a Covid test which showed a positive result. They said, you got to be kidding me. The staff then looked at the family member and indicated they planned to perform another test but if that test result was positive they had to take the resident home. The 2nd test came back positive also so the facility staff looked at the family member and said they planned to load the resident into the facilities van and take her home. Staff A drove the resident in the facility van to her own home and left her in her front lawn with a commode, wheelchair, and a lift strap (gait belt). During the time Staff A remained at the resident's house she heard another family member as he called public health for guidance. The staff member then became angry and stated she planned to leave as a means not to get caught in the cross fire. The family returned the resident to the ED where they admitted her for 10 days on the medical/surgical floor until her 10 days of quarantine had been completed. The family member indicated she felt bad for the resident because the event traumatized her and she had been in pain as she sat in a w/c for hours that day and never had her foot elevated. During interview 7.27.23 at 1:40 p.m. the above same family member and other family member had been present when staff propelled the resident outside of the facility on 6.6.23 as they waited 10 minutes for the return of the facility van. Staff A then transported the resident home via the facility van and at that point 3 family members had been present when Staff A arrived at the resident's home along with the local chief of police who had arrived off duty and in street clothes. The police chief had been called by family as the resident and himself worked together for 18 years. The family member described all people present as hot, sweaty, and emotional. The family member indicated the facility staff had since stated the resident verbalized a desire to have used the restroom when she first presented at the nursing facility as a blatant lie. During an interview 7.26.23 at 12:57 p.m. the resident indicated on 6.6.23 she fell at work which resulted in a broken foot/ankle and had been not able to return to her home due to a non-weight bearing status plus a w/c could not have fit into her home. The Resident stated the hospital discharged her home but the family present stated lets go to the nursing facility. Upon arrival 2 family members entered the facility and Staff A and Staff B, Admissions Director and a family member came out to the car and stated they would take the resident under their care. At that point, a family member drove the resident around to the back of the building where they brought a w/c for assistance to have gotten the resident into the facility. Staff A transferred the resident into the w/c and brought her into a small family type room where Staff A performed an assessment and paperwork. Staff A then left and returned and stated your room is ready and wheeled the resident to her room. Staff assisted the resident to the bathroom and into a bed and that had been when staff performed a Covid test which the result was positive. The staff then looked at 1 of the resident's family members and stated the resident could not have stayed in the facility. The staff left the resident's room and returned all PPE'd (personal protective equipment) up, wheeled the resident outside of the facility with a walker and commode as they waited for maybe 10 minutes for the return of the facility van. The resident described herself as out of it because of the pain. The resident had been loaded into the facility van and transferred home by Staff A who backed the van up to the stairs in front of the resident's home and unloaded her. The resident described the situation as stupid because she had been unable to get into her house anyway. At that point a family member called public health and wanted to know the current Covid restrictions. Staff A heard the call, became upset, and left the resident's house which left 3 family members plus her boss, the chief of police. They all sat outside for approximately 1/2 hour or until the decision had been made to take her back to the hospital. The resident described 6.6.23 as not a good day and that she had been beside herself. The resident stated, not only had the facility placed her in that situation but also her family when they left her as she sat in a w/c by the front steps of her home. Plus when they wheeled her out of the facility and onto a sidewalk with a commode positioned right beside her where family and/or friends of another resident watched her which caused humiliation. During an interview 7.26.23 at 1:42 p.m. Staff A confirmed on 6.6.23 the resident and 2 family members pulled up into the facility parking lot and 1 or both family members entered the facility. The family indicated the resident had been discharged from the hospital and they just drove around and wondered what they could have done and they wondered if the facility could have helped them. Staff A and Staff B went outside with family and found the resident positioned in the front seat of the car and as non-weight bearing due to a fractured foot. The resident stayed in the car and the family and staff members returned to the facility. Staff called the resident's insurance company for approval, the police department, hospital, and workman's compensation. At that time they had been at the 3 hour mark from when the resident left the local ED and had been still waiting on the ED history and physical report so the staff went outside and brought the resident into the facility to have used the restroom in the room they they planned to admit the resident into. The staff members obtained a gait belt, placed it on the resident, and pivot transferred her onto the toilet. Upon conclusion the staff members assisted the resident into a wheel chair. The staff member had been unsure about the length of time the resident sat in the wheel chair but she believed it became painful for the resident so they assisted the resident into bed. At that point Staff B started an assessment and ran a Covid test which had a positive result. At that point the staff members got the Director of Nursing (DON) involved for guidance because they had no paperwork from the ED and now they had a Covid positive resident, not enough staffing to isolate her for Covid and they could not admit her. The staff member stated they left the resident positioned in the bed until the facility van arrived. As the staff member had been shown pictures of the resident as she sat outside the facility the staff member changed her mind and indicated they took the resident to the curb for an unknown amount of time. Once the van arrived the staff member transported her home and when they arrived the Chief of Police and 3 family members had been present. All parties discussed ways to have safely transferred the resident into the house. At one point a family member called Public Health as she had been outside with the resident positioned in a wheel chair on the sidewalk. The staff member stated there had been no way to get her into the house and the situation had not been safe anymore. The staff member indicated the resident and a family member understood because her hands were tied there had been no way for her to have assisted the resident anymore and she felt family wanted her to do something out of her scope of practice even thou she confirmed her status as a CNA. The staff member described the temperature as hot. During an interview 7.27.23 at 3:36 p.m. Staff B stated herself and Staff A had been in her office as they worked on another admission. Staff A went up to the front desk and retrieved some papers they had just printed when she observed 2 of the resident's family members as they stood at the front desk. As Staff B worked on her computer in her office Staff A tapped on her office window as all 3 stood outside and Staff A waved her outside. When they arrived at the resident's car she had been positioned in the passenger seat with the window rolled down. The family and resident tried to explain the situation that the local ED discharged her with a script to go to a local long term medical equipment company for a bariatric walker and they did not have one. Since then they drove around for over an hour. Staff B then invited the family into her office as Staff A planned to stay with the resident however she indicated she would have been fine in the car. Two family members and Staff A and B went into the facility and into their office. The 1st thing Staff B stated was they needed to call the local ED to find out what had been going on. The provider who assessed the resident in ED stated they had no reason for admission following ED treatment. Staff B explained to the provider the family went to the long term medical provider but could not get a walker at that time and the family felt they could not get the resident into her house because as it had not been set up for her current level of care. Staff B indicated Staff A had been on the telephone with workman's compensation at which time a family member offered to have just paid privately. Once the family stated the would pay privately Staff B called the resident's insurance company, completed a Preadmission Screening and Resident Review (PASRR) assessment and checked the resident's status on the sex offender website. Staff B indicated the only thing they did not have at that time had been the ED note because the documentation had not been completed at that time. At that point, Staff A went outside with family and the resident stated she had to go to the bathroom so they obtained a wheel chair and got her into the room they planned to admit the resident into. Staff B called the resident's primary physician and received verbal orders for admission. Staff B indicated they asked family and resident prior if she displayed any Covid symptoms and she denied symptoms and stated the thing she had was allergies. The staff member performed a Covid test and her leg ached and the only way for elevation of the leg had been in bed. The resident had been transferred to bed with 1 staff assistance. As staff elevated the resident's leg she looked over and observed the positive Covid test. The staff members messaged the DON and reported the situation. The DON indicated the facility had not enough staff and they could not have not have the resident in the building right then. Staff B returned to the room and informed the family the resident could not stay at the facility so the family planned to take the resident to her home. The staff member's assisted the resident, along with family, outside and waited for the facilities van to have returned from the hospital which took approximately 10 minutes. As they stood outside another family member arrived and asked if there had been anyway they could have kept the resident at the facility and they said they had not enough staff on duty. The staff member confirmed there had been family of an unknown resident that congregated in the area when the resident had been outside of the facility and awaited the arrival of the van. During an interview 8.2.23 at 9:30 a.m. the state climatologist indicated the weather on 6.6.23 from 12 p.m. until approximately 3:30 p.m. as follows: Temperature 79-80 degrees Fahrenheit (F), humidity at 48-60%, winds at 3-8 miles per hour (mph), hazy, and a heat index of 82 degrees F. Staff A completed An Iowa Level 1 Form Preadmission Screening and Resident Review (PASSR) form dated 6.6.23 at 11:06 a.m. A Wellmark Blue Cross and Blue Shield - Eligibility & Benefits form had been completed by the facility staff 6.6.23 at 11:34 a.m. A Search Results - Iowa Sex Offender Registry form had been performed 6.6.23 at 12:29 p.m. A photo dated 6.6.23 at 1:44 p.m. revealed the resident as she laid supine in one of the facilities beds. A photo dated 6.6.23 at 3 p.m. revealed the resident positioned in a w/c on the sidewalk outside of her home with two (2) family members and Staff A without her foot elevated. During an interview 7.27.23 at 9:26 a.m. the chief of police confirmed he went to the resident's house when the nursing facility dropped her off and because they could not get her into the house they just left her on the sidewalk in front of her house. The chief of police confirmed Staff A had been present but when a family member called public health she became quite agitated and left. During an interview 7.28.23 at 9:38 a.m. the chief of police confirmed he arrived at the resident's house in street clothes and his personal truck on 6.6.23 as a friend and an employer and indicated he felt the facility left the resident in not a good place as she needed to have been in a nursing home which became apparent when she stayed at the hospital for 10 days.