Inspection Reports for Knickerbocker Villa
304 SOUTH SECOND STREET,, CLEARFIELD, PA, 16830
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
4.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
2% better than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
43% occupied
Based on a October 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 30
Capacity: 70
Deficiencies: 0
Date: Oct 15, 2025
Visit Reason
The inspection was conducted as a complaint and incident investigation during an unannounced partial inspection.
Complaint Details
The inspection was triggered by a complaint and incident, but no deficiencies or citations were found.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
License Capacity: 70
Residents Served: 30
Secured Dementia Care Unit Capacity: 17
Secured Dementia Care Unit Residents Served: 9
Current Hospice Residents: 4
Residents Age 60 or Older: 29
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 13
Residents Receiving Supplemental Security Income: 0
Residents Diagnosed with Intellectual Disability: 0
Residents with Physical Disability: 0
Inspection Report
Complaint Investigation
Census: 30
Capacity: 70
Deficiencies: 4
Date: Aug 18, 2025
Visit Reason
The inspection was conducted as a complaint investigation following a report of alleged abuse and privacy violations involving a resident while hospitalized.
Complaint Details
The complaint was substantiated based on video evidence showing staff person A entering the resident's locked bedroom multiple times, removing drinks, and going through personal belongings while the resident was hospitalized. Staff person A was terminated and mandatory abuse reports were filed with local authorities and agencies.
Findings
The investigation found that staff person A entered a resident's locked bedroom without permission, went through personal belongings, and took items including drinks and perfume. Staff person A was terminated, and mandatory abuse reports were filed. Additional deficiencies included unqualified direct care staff and incomplete resident assessments.
Deficiencies (4)
Resident was neglected and abused by staff person A who entered the resident's locked bedroom without permission, went through personal belongings, and took items.
Resident's right to privacy was violated by staff person A entering the locked bedroom and accessing personal items without permission.
Direct care staff person A did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
Resident assessment did not include diagnoses of Seizures and Unspecified Falls as indicated on medical evaluation.
Report Facts
License Capacity: 70
Residents Served: 30
Secured Dementia Care Unit Capacity: 17
Secured Dementia Care Unit Residents Served: 10
Hospice Current Residents: 3
Residents Diagnosed with Mental Illness: 20
Residents Aged 60 or Older: 29
Residents with Mobility Need: 14
Residents with Physical Disability: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Direct Care Staff | Named in abuse and privacy violation findings; terminated for misconduct |
| Administrator | Interviewed staff person A, terminated employment, notified authorities, and implemented corrective actions |
Inspection Report
Complaint Investigation
Census: 32
Capacity: 70
Deficiencies: 6
Date: Apr 28, 2025
Visit Reason
The inspection was a partial, unannounced complaint and interim investigation conducted on 04/28/2025 to review compliance with resident care and facility regulations.
Complaint Details
The inspection was complaint-related and interim in nature, triggered by concerns about resident care and compliance. Substantiation status is not explicitly stated.
Findings
The inspection found multiple deficiencies including failure to provide required assistance with activities of daily living, inadequate staffing during night hours, failure to follow prescriber's orders for blood sugar testing and medication administration, delayed updates to resident assessments after condition changes, improper issuance of a 30-day discharge notice for nonpayment, and incomplete medical evaluations for residents in the secured dementia care unit.
Deficiencies (6)
Failure to provide assistance with eating/drinking as indicated in resident's assessment and support plan, resulting in hospitalizations.
Inadequate staffing from 7:45 p.m. to 7:00 a.m. with only 2 staff present, insufficient for resident assistance and emergency evacuation.
Failure to follow prescriber's orders for blood sugar testing and medication administration as prescribed.
Resident assessments not updated timely after significant changes in condition and behaviors.
Improper issuance of 30-day discharge notice for nonpayment without documented nonpayment period.
Medical evaluations for residents admitted to secured dementia care unit did not indicate need for secured unit placement.
Report Facts
License Capacity: 70
Residents Served: 32
Residents in Secured Dementia Care Unit: 9
Current Hospice Residents: 3
Residents with Mobility Need: 18
Residents 60 Years or Older: 31
Staffing Hours - Total Daily Staff: 50
Staffing Hours - Waking Staff: 38
Maximum Safe Evacuation Time: 300
Staff Present During Night Shift: 2
Inspection Report
Renewal
Census: 30
Capacity: 70
Deficiencies: 8
Date: Feb 25, 2025
Visit Reason
The inspection was conducted for renewal, complaint, and incident reasons as part of a full unannounced inspection on 02/25/2025.
Findings
The inspection identified multiple deficiencies including missing fee schedules in resident contracts, lack of CPR-certified staff during a night shift, leaking ceiling in a conference room, snow/ice obstructing an emergency exit, torn mattress exposing springs, missing refrigerator thermometer, medication administration errors, and incomplete preadmission screening forms. Plans of correction were accepted and implemented by 05/12/2025.
Deficiencies (8)
Resident-home contracts for residents #1, #2, #3, and #4 did not include a fee schedule of actual amounts charged for available services.
No staff person certified in first aid and CPR was present from 7:30 p.m. on 2/18/25 to 3:00 a.m. on 2/19/25 when 30 residents were present.
Ceiling in the small conference room was actively leaking a dark brown substance, staining 2 ceiling tiles, one hanging down approximately 8 inches.
Exterior walkway outside emergency exit door #6 was covered with approximately 2 inches of snow/ice at 11:15 a.m., obstructing egress.
Resident #3's mattress had 2 approximate 1 inch tears, one exposing a sharp end of a metal spring.
No thermometer was present in the main refrigerator in the kitchen at 10:49 a.m.
Medication administration errors for residents #2, #5, and #7 including incorrect blood glucose documentation, glucometer readings not matching MAR, and medication given not according to prescriber's orders.
Resident #1's preadmission screening form and written cognitive preadmission screening for Secure Dementia Care Unit admission were not completed on proper dates.
Report Facts
Residents present during CPR deficiency: 30
Snow/Ice obstruction: 2
License Capacity: 70
Residents Served: 30
SDCU Capacity: 17
SDCU Residents Served: 8
Inspection Report
Renewal
Census: 31
Capacity: 70
Deficiencies: 0
Date: Apr 30, 2024
Visit Reason
The inspection was conducted as a renewal licensing inspection of the facility.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Report Facts
Residents Served: 31
License Capacity: 70
Secured Dementia Care Unit Capacity: 17
Secured Dementia Care Unit Residents Served: 8
Current Hospice Residents: 4
Residents Age 60 or Older: 30
Residents with Supplemental Security Income: 1
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 8
Residents Diagnosed with Intellectual Disability: 0
Residents with Physical Disability: 0
Inspection Report
Complaint Investigation
Census: 32
Capacity: 32
Deficiencies: 0
Date: Dec 6, 2023
Visit Reason
The inspection was conducted due to a complaint and a change in legal entity at the facility.
Complaint Details
The inspection was complaint-related and the findings indicate no deficiencies or citations were found, implying the complaint was not substantiated.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Report Facts
Residents Served: 32
License Capacity: 32
Secured Dementia Care Unit Capacity: 17
Secured Dementia Care Unit Residents Served: 10
Hospice Current Residents: 2
Residents Receiving Supplemental Security Income: 1
Residents Age 60 or Older: 31
Residents Diagnosed with Mental Illness: 3
Residents Diagnosed with Intellectual Disability: 0
Residents with Mobility Need: 11
Residents with Physical Disability: 0
Inspection Report
Renewal
Census: 28
Capacity: 70
Deficiencies: 1
Date: Feb 8, 2022
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license.
Findings
The submitted plan of correction was determined to be fully implemented following the inspection. A deficiency was noted regarding inoperable thermometers in refrigerators, which was corrected with new thermometers and a new tracking system for monitoring temperatures.
Deficiencies (1)
Thermometers in refrigerator #2 and in the main refrigerator were not operable.
Report Facts
License Capacity: 70
Residents Served: 28
Total Daily Staff: 36
Waking Staff: 27
Secured Dementia Care Unit Capacity: 17
Secured Dementia Care Unit Residents Served: 8
Hospice Current Residents: 4
Residents Receiving Supplemental Security Income: 1
Residents 60 Years or Older: 27
Residents Diagnosed with Mental Illness: 3
Residents with Mobility Need: 8
Notice
Capacity: 70
Deficiencies: 0
Date: Apr 30, 2021
Visit Reason
The document serves as a renewal notification for the operation of Knickerbocker Villa Personal Care Home and informs that an onsite inspection will be conducted within the next twelve months as required by state regulations.
Findings
No inspection findings are reported in this document; it is a license renewal notice with an enclosed certificate of compliance specifying the facility's capacity and service type.
Report Facts
Maximum capacity: 70
Secure Dementia Care Unit capacity: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter |
Inspection Report
Renewal
Census: 31
Capacity: 70
Deficiencies: 4
Date: Mar 24, 2021
Visit Reason
The inspection was conducted as a renewal licensing inspection of Knickerbocker Villa on 03/24/2021.
Findings
The inspection found multiple deficiencies including a direct care staff member providing unsupervised ADL services without completing required training, an entrapment hazard due to an uncovered opening on a resident's enabler bar, fire exit doors not properly latching or closing, and missing grab bars and handrails in bathrooms. Plans of correction were accepted and implemented for all deficiencies.
Deficiencies (4)
Direct care staff person providing unsupervised ADL services without completing Department-approved direct care training and competency test.
Resident #1 has an enabler bar on bed with an uncovered opening measuring approximately 18" wide by 12" high and a 5" gap between the bar and mattress, posing an entrapment hazard.
Fire exit door #3 does not securely latch when closed and fire exit door #4 does not close completely on its own.
No grab bar, hand rail or assist bar for the showers in the bathrooms in bedrooms (redacted).
Report Facts
License Capacity: 70
Residents Served: 31
Secured Dementia Care Unit Capacity: 17
Secured Dementia Care Unit Residents Served: 10
Hospice Current Residents: 2
Residents Receiving Supplemental Security Income: 5
Residents Age 60 or Older: 30
Residents Diagnosed with Mental Illness: 4
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 13
Residents with Physical Disability: 0
Total Daily Staff: 44
Waking Staff: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janine Wenzig | Signed correspondence regarding inspection and plan of correction. | |
| Direct care staff person A | Named in deficiency for providing unsupervised ADL services without required training. | |
| Administrator | Responsible for contacting help desk, retrieving certificates, and implementing corrective actions. | |
| Clinical Coordinator | Failed to ensure no entrapment hazard with enabler bar installation. | |
| Maintenance Director | Failed to monitor and repair fire exit doors and install grab bars and handrails. |
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