Health inspection·February 4, 2026

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that pressure ulcer care/prevention treatments were provided as ordered for two of four residents reviewed (Resident 3, 4). Findings include: An admission change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated December 30, 2026, revealed that the resident was cognitively intact, stage 4 pressure ulcer(full thickness skin and tissue loss exposing muscle, tendon or bone) on admission, required assistance from staff for daily care needs, and had medical diagnosis that included stroke. Physician's orders for Resident 3, dated January 6, 2026, included an order for the resident to have his left buttock cleansed with wound cleanser, pat dry, pack with iodoform packing strip and cover with silicone border every dayshift. A review of Resident 3's January 2026 Treatment Administration Record was reviewed and there is no documented evidence his treatment was completed per physician orders on January 12, 2026, and January 18, 2026. Physician's orders for Resident 3, dated January 19, 2026, included an order for the resident to have his left buttock cleansed with wound cleanser, pat dry, pack with iodoform packing strip, apply zinc oxide paste to peri-wound, cover with silicone border every dayshift. A review of Resident 3's January 2026 Treatment Administration record was reviewed and there is no documented evidence his treatment was completed per physician orders on January 24, 2026, and January 25, 2026. An interview with the Director of Nursing on February 4, 2026, at 12:12 p.m. confirmed that there was no documented evidence that Resident 3's wound treatments were completed as ordered on the dates listed above. A quarterly MDS assessment for Resident 4, dated December 20, 2025, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, had pressure ulcer, and had medical diagnosis that included dementia.Review of skin and wound notes for Resident 4 dated December 22, 2025, January 2, 2026, and January 9, 2026, included that the wound treatment recommendations to the right and left buttocks pressure ulcers were to cleanse with wound cleanser or normal saline (salt water), apply Zinc Oxide Paste to base of the wound, secure with a dry dressing, and change daily, and as needed . However, review of the Treatment Administration Record (TAR) for Resident 4 dated January 2026, revealed that on January 1 through the 12, 2026, the treatment to the right and left buttocks pressure ulcers was documented as being left open to air, with no dry dressing. A skin and wound note dated January 26, 2026, included that the wound treatment recommendations to the right and left buttocks pressure ulcers were to cleanse with wound cleanser or normal saline (salt water), apply Zinc Oxide Paste to base of the wound, secure with bordered gauze, and change daily, and as needed. However, review of the TAR dated January 2026 revealed that the treatment to the right and left buttocks pressure ulcers was documented as being completed three times a day on January 26, 2026, through February 3, 2026. Interview with the Assistant Director of Nursing on February 4, 2026, at 2:11 p.m. confirmed that there was no documented evidence that the wound care consultant's recommendations for the treatments to Resident 4's pressure ulcers were being completed as Residents Affected - Few Page 1 of 2 395500 395500 02/04/2026 Twin Lakes Rehabilitation and Healthcare Center 227 Sand Hill Road Greensburg, PA 15601

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few ordered. 28 Pa. Code 211.12(d)(5) Nursing services. Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that pressure ulcer care/prevention treatments were provided as ordered for two of four residents reviewed (Resident 3, 4). Findings include: An admission change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated December 30, 2026, revealed that the resident was cognitively intact, stage 4 pressure ulcer(full thickness skin and tissue loss exposing muscle, tendon or bone) on admission, required assistance from staff for daily care needs, and had medical diagnosis that included stroke. Physician's orders for Resident 3, dated January 6, 2026, included an order for the resident to have his left buttock cleansed with wound cleanser, pat dry, pack with iodoform packing strip and cover with silicone border every dayshift. A review of Resident 3's January 2026 Treatment Administration Record was reviewed and there is no documented evidence his treatment was completed per physician orders on January 12, 2026, and January 18, 2026. Physician's orders for Resident 3, dated January 19, 2026, included an order for the resident to have his left buttock cleansed with wound cleanser, pat dry, pack with iodoform packing strip, apply zinc oxide paste to peri-wound, cover with silicone border every dayshift. A review of Resident 3's January 2026 Treatment Administration record was reviewed and there is no documented evidence his treatment was completed per physician orders on January 24, 2026, and January 25, 2026. An interview with the Director of Nursing on February 4, 2026, at 12:12 p.m. confirmed that there was no documented evidence that Resident 3's wound treatments were completed as ordered on the dates listed above. A quarterly MDS assessment for Resident 4, dated December 20, 2025, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, had pressure ulcer, and had medical diagnosis that included dementia. Review of skin and wound notes for Resident 4 dated December 22, 2025, January 2, 2026, and January 9, 2026, included that the wound treatment recommendations to the right and left buttocks pressure ulcers were to cleanse with wound cleanser or normal saline (salt water), apply Zinc Oxide Paste to base of the wound, secure with a dry dressing, and change daily, and as needed . However, review of the Treatment Administration Record (TAR) for Resident 4 dated January 2026, revealed that on January 1 through the 12, 2026, the treatment to the right and left buttocks pressure ulcers was documented as being left open to air, with no dry dressing. A skin and wound note dated January 26, 2026, included that the wound treatment recommendations to the right and left buttocks pressure ulcers were to cleanse with wound cleanser or normal saline (salt water), apply Zinc Oxide Paste to base of the wound, secure with bordered gauze, and change daily, and as needed. However, review of the TAR dated January 2026 revealed that the treatment to the right and left buttocks pressure ulcers was documented as being completed three times a day on January 26, 2026, through February 3, 2026. Interview with the Assistant Director of Nursing on February 4, 2026, at 2:11 p.m. confirmed that there was no documented evidence that the wound care consultant's recommendations for the treatments to Resident 4's pressure ulcers were being completed as ordered. 28 Pa. Code 211.12(d)(5) Nursing services. 395500 Page 2 of 2