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All of the puppets are at their highest difficulty (100%).
The level itself is covered in lots and lots of blood, as if there was a massive massacre. the Nightmare appears on the TV in this level. His words are in reverse. Note the blue background.
This article or section contain speculation, so please keep that in mind while reading.
Since the level is covered in blood, we can say that this symbolizes the death of Tim Denson's daughter. The blue background from Level 3: Calm before the storm is still there, however we can say that it signifies nothing. The level name is "What Have You Done?", This can possibly be the Nightmare talking to Tim, reminding him of his murderous deed. Same scenario can apply for Level 2: What did you do?, Level 6: You've gone too far, and possibly Level 9: Turn Around. This is also the level where the first game puppets are on the couch watching TV.