Van Duyn Center: Air Mattress Settings Wrong for Wound Care - NY
One of those residents, identified in inspection records as Resident #114, had an active sacral wound. The other, Resident #71, was at risk of developing one.
The mattresses are designed to relieve pressure on vulnerable skin. The way they work depends on being set to the correct weight for the person lying on them. Set too low, the mattress doesn't provide enough support. Set too high, it can cause harm. Neither resident's mattress was set correctly.
Resident #114's mattress was set to 420 pounds. Resident #71's mattress was set to a figure inspectors redacted from the public record. Neither resident weighed what their mattress was calibrated for. The Assistant Director of Nursing told inspectors that Resident #71 was "tiny" and nowhere near the weight on the setting. Resident #114, followed by the wound care team for a sacral wound that had stayed roughly the same, did not weigh 420 pounds either.
The nursing staff had been checking the mattresses every shift and documenting those checks on the Treatment Administration Record. What they were checking, it turned out, was whether the mattress was on and inflating. Nobody was checking the weight setting.
The Assistant Director of Nursing, interviewed on April 17, was direct about it: before the day prior, she had not realized air mattresses had a weight setting at all. The checks, as she described them, confirmed the mattress was running. They did not confirm it was running correctly for the person in the bed.
The wound nurse who spoke with inspectors on the final day of the inspection, April 18, explained the stakes plainly. If the setting was too low, the mattress wouldn't work. If it was too high, it could cause harm. For Resident #71, an incorrect setting raised the chances of developing a pressure wound. For Resident #114, it raised the chances of the existing sacral wound getting worse. The nurses signing off on the Treatment Administration Record were attesting that inflation and function had been verified. The wound nurse told inspectors that checking the weight setting was part of checking function, and if it had been signed off, it should have been checked.
It hadn't been.
The Director of Central Supply described the setup process to inspectors: wound nurses put in a work order, central supply installed the mattress, the weight was obtained by asking a nurse aide or the nurse manager, and then the wound nurses were supposed to confirm the setting was accurate. That confirmation, in practice, wasn't happening. Nursing staff told inspectors they did not check the mattresses after installation, which meant there was no way to know whether the settings were ever right.
The gap between what the records showed and what was actually being verified is the core of what inspectors documented. Shift after shift, staff initialed the Treatment Administration Record. Shift after shift, the weight settings on both mattresses went unchecked. Resident #114's sacral wound held steady, neither healing nor clearly worsening. Resident #71, small and with limited mobility in bed, remained on a mattress that may have been providing little of the pressure relief it was prescribed to provide.
Van Duyn Center for Rehabilitation and Nursing is located at 5075 West Seneca Turnpike in Syracuse. The inspection was completed April 18, 2025.
The wound nurse's explanation stayed factual and procedural throughout the interview. The appropriate weight setting, she said, was part of checking function. If it was signed off, it should have been checked. For two residents, one of them already wounded, it was not.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Van Duyn Center For Rehabilitation and Nursing from 2025-04-18 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
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Last verified: October 28, 2026 · Our methodology
Van Duyn Center For Rehabilitation And Nursing in SYRACUSE, NY was cited for violations during a health inspection on April 18, 2025.
One of those residents, identified in inspection records as Resident #114, had an active sacral wound.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.