Twin Lakes Rehabilitation And Healthcare Center

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

prevent the alarm from going off due to the high winds that would set off the alarm. She stated that she was not usually on that unit and was unsure how long the zip ties and gauze were on the doors.Interview with Maintenance Worker 6 on January 2, 2026, at 9:42 a.m. revealed that he was not aware of any exit doors being secured with zip ties or rolled gauze.Interview with the Nursing Home Administrator on January 2, 2026, at 9:45 a.m. revealed that the wind would rattle the emergency exit doors causing the door alarm to frequently trigger, which required staff to go to the doors and re-set the alarm. He stated that he was not aware that the exit doors on the short halls of the [NAME] and [NAME] units were secured shut with zip ties and rolled gauze. He confirmed that the doors should not have been secured shut with zip ties or rolled gauze and he was unaware who applied the zip ties and rolled gauze.Interview with the Director of Nursing

on January 2, 2026, at 12:36 p.m. confirmed that she was not aware that there were emergency exit doors secured shut with zip ties and gauze on the [NAME] and [NAME] units.On January 2, 2026, at 12:41 p.m.

the Nursing Home Administrator was informed that the health and safety of the residents was placed in Immediate Jeopardy due to the emergency exit doors on the short halls of the [NAME] and [NAME] units being secured shut with zip ties and rolled gauze which would have prevented resident egress from the facility during and emergency. The Immediate Jeopardy template was also provided to the Nursing Home Administrator.The facility submitted and implemented an immediate action plan that included removing the zip ties and rolled gauze that secured the emergency exit doors shut, inspected all doors to ensure proper functioning, educated all staff on emergency doors and route of egress and the facility's policy that all emergency exit doors should be unobstructed, and maintenance would check all exit doors for proper functioning on a daily basis.The Immediate Jeopardy was lifted on January 2, 2026, at 4:46 p.m. when it was confirmed that the facility had removed the zip ties from the emergency exit doors, ensured that all exit doors were accessible, staff were educated, and all emergency exit doors were inspected/repaired by a door company.28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(e)(1) Management.28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

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Printed: 04/13/2026 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

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)

F 0835

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

review of policies and employee job descriptions, as well as observations and staff interviews, it was determined that the facility's administration, Nursing Home Administrator and Director of Nursing, failed to effectively use its resources to promote resident safety and maintain the highest practicable physical well being of residents in the facility by failing to ensure that emergency exit doors were accessible to residents, allowing egress to the outside during an emergency situation, placing the residents at risk for serious harm which created an Immediate Jeopardy situation.Findings included:The job description for the Nursing Home Administrator, undated, revealed that the administrator's essential job functions included the planning, developing, organizing, implementing and directing of programs and activities; assuring that the facility was properly maintained, and clean and safe for resident comfort and conveniences; and implement an effective accident prevention program. The facility failed to ensure these responsibilities were carried out, as evidenced by the emergency exit doors being secured shut with zip ties and rolled gauze, ensuring that all emergency exits were accessible to residents, allowing egress during an emergency situation. This demonstrated a lack of effective oversight to address the safety of residents during an emergency situation.The job Description for the Director of Nursing, dated June 25, 2025, indicated that the Director of Nursing was responsible for the planning, developing, organizing, and directing the overall operation of the Nursing Service Department in accordance with current Federal, State, and local standards, guidelines and regulations that governed the facility; develop, maintain and periodically update written policies and procedures that govern the day to day functions of the nursing services department; monitor nursing service personnel to ensure that they are following established safety regulations in the use of equipment and supplies; and ensure that all resident care rooms, treatment areas, etc. are maintained in a clean, safe and sanitary manner. The DON failed to ensure that all emergency exit doors were accessible to residents, allowing egress to the outside during an emergency situation.Based on the findings the facility's inability to ensure that all emergency exits were accessible to residents and allowed egress during an emergency situation resulted in Immediate Jeopardy to the health and safety of residents on the [NAME] and [NAME] units. This demonstrates a systemic failure in the administration's oversight and resource allocation to ensure a safe environment for residents.The deficiency cited under the Code of Federal Regulatory Groups for Long Term Care, Quality of Care (F-F689) 483.25(d)(1)(2) Accidents, revealed the facility's administration did not fulfill essential job duties to ensure resident safety and regulatory compliance. This included a failure to ensure that emergency exits on the [NAME] and [NAME] units were accessible to residents and allowed egress to the outside during an emergency situation.Refer F-F689 28 Pa. Code: 201.14 (a) Responsibility of licensee28 Pa. Code: 201.18 (b)(1)(3)(e)(1) Management28 Pa. Code 211.12 (c)(d)(1)(3)(5)Nursing services

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet