PHILADELPHIA (AP) — Administrators failed in their essential duties and responsibilities at a Philadelphia senior care facility where the father of President Donald Trump's former national security adviser died after a fall, according to a Pennsylvania Health Department report.

The 141-page report said Herbert R. McMaster Sr.'s fatal fall was his fifth during a four-day stay at the Cathedral Village retirement community, where he was admitted for rehabilitation following a stroke. The 84-year-old retired U.S. Army officer died April 13, about eight hours after stumbling and hitting his head.

The report, released Saturday, said staff failed to develop a fall prevention plan even though his medical records indicated it was required; failed to complete required neurological checks after his falls; and did not attempt to perform CPR to resuscitate McMaster when he was found unresponsive, according to facility records.

Christann Gainey, a 30-year-old nurse who worked for an outside agency and was temporarily staffing at the facility, was arrested last month on charges including involuntary manslaughter and tampering with paperwork. Gainey is scheduled to make an appearance in court Tuesday for a preliminary hearing. A phone call to her attorney, Sharon Piper, was not immediately returned Monday.