Health inspection·January 2, 2026

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policies, observations and staff interviews, it was determined that the facility failed to ensure residents' environment remained free of accident hazards, and failed to ensure a safe route of egress through emergency exit doors for residents on two of three units ([NAME] and [NAME] units), which placed residents in immediate jeopardy of the likelihood of serious bodily injury, harm or death. Findings include: The facility's policy regarding exits or means of egress, dated July 28, 2025, indicated that the facility had designated exits for each area of the building to allow for rapid evacuation. Exit doors would remain unlocked at all times and residents were never denied access to unlocked exits. Exit doors were to never be blocked, even briefly.The maintenance logbook for December 2025 and January 2026 revealed that the doors, locks, gates and alarms on the [NAME] and [NAME] short and long hall doors, had their operation tested daily on December 29, 30, and 31, 2025. They were marked as Pass on the logbook for these dates and there was no mention of zip ties or rolled gauze being in place. There was no documented evidence that the doors on the [NAME] and [NAME] short and long halls were checked for operation on January 1, 2026, due to the Maintenance Director being scheduled off. The instructions for checking the doors and hardware for proper operation and condition, undated, indicated that the door closures were to be checked for any obstructions and any discrepancies were to be noted.Observations on January 2, 2026, at 9:19 a.m. revealed that the two emergency doors on the short hall of the [NAME] unit had the handles to the two doors secured shut with a zip tie (self-locking plastic device), preventing egress to the outside.Interview with Licensed Practical Nurse 1 on January 2, 2026, at 9:22 a.m. revealed that she was the medication nurse on the short hall of the [NAME] unit and she was not aware that there were zip ties on the emergency exit doors preventing egress.Interview with Nurse Aide 2 on January 2, 2026, at 9:26 a.m. revealed that she was not aware that there were zip ties securing shut the emergency exit doors on the [NAME] short hall. She indicated that the wind would blow on the doors and cause the alarm to sound.Interview with the Registered Nurse Supervisor 3 on January 2, 2026, at 10:36 a.m. revealed that the wind would cause the emergency exit doors on the short hall of the [NAME] unit to alarm, but she was unaware of any exit doors being secured shut with zip ties.Observations on January 2, 2026, at 9:20 a.m. revealed that the two emergency doors on the short hall of the [NAME] unit had the handles to the two doors secured shut with a zip tie and had rolled gauze wrapped tightly around the door handles and stretched to attach to the railing adjacent to the doors preventing egress to the outside.Interview with Nurse Aide 4 on January 2, 2026, at 9:22 a.m. revealed that the emergency exit doors on the short hall of the [NAME] unit would alarm frequently due to the high winds but was not aware that the exit doors were secured shut with zip ties. Interview with the Registered Nurse 5 on January 2, 2026, at 9:26 a.m. confirmed that the emergency exit doors of the [NAME] unit were zip tied shut and had rolled gauze wrapped around the handles. She indicated that they were probably placed on the doors to (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 395500 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395500 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Twin Lakes Rehabilitation and Healthcare Center 227 Sand Hill Road Greensburg, PA 15601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)