May 18, 2018 - The Department issued a citation for two separate violations which, at the time the citation was issued, were represented by a single data prefix tag. The two violations must be represented by two citations even though the citations use the same tag, F323. The first deficiency tag F323 is for a violation of 42 C.F.R. § 483.25(d) (2017). The correct severity of this citation is level J, immediate jeopardy. The Facility failed to ensure R1 was properly supervised or devices were in place to keep R1 free from accidental falls, a hazard R1 was susceptible to. As a result of this failure, R1 fell and died. The second deficiency tag F323 is for a violation of 42 C.F.R. § 483.25(n)(1) and (2) (2017). The correct severity of this citation is level D, no actual harm with potential for more than minimal harm that is not immediate jeopardy. The Facility failed to properly assess R1’s risk for entrapment in transfer bars prior to installing and using them, reviewing the risks with R1, and obtaining R1’s informed consent prior to installation and use. It is not clear that had the risk assessment been completed, and the risk of using the bars shared with R1, that R1 would have declined to have the transfer bars in place and use them.