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 (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 2 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 02/04/2026 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)