Van Duyn Center: Bed Rail Safety Failures Cited - NY
The resident, identified in inspection records as Resident 41, told inspectors on April 10 that they only got out of bed for appointments and used the rails to hold onto during wound care. They had kept the rails since arriving at the facility and wanted them. A certified nurse aide confirmed the resident used the bars to brace during wound dressing and linen changes, then added something that stopped the inspection cold: "The residents were not supposed to have them, and the facility had tried to take them off, but the resident refused."
That was not the end of the problem. It was the beginning.
A physician order for the bed rails had been discontinued in the facility's system on August 12, 2024, when the resident was hospitalized. Nobody reordered it when the resident came back. The Assistant Director of Nursing acknowledged this to inspectors on April 17, saying she was responsible for ensuring quarterly assessments were completed and that they "just did not get done." There was one completed in March. Before that, the last one was a year earlier.
The Director of Rehabilitation laid out what the assessments were supposed to catch. Resident 41 required total assistance for a long time and had no strength in their hands. The rails created a risk of bruising, entrapment, and getting fingers caught. The quarterly occupational therapy screens, which were supposed to document whether the resident still needed the rails and whether they remained appropriate, had not been completed as required. The ones that were completed said nothing about bed rail use at all.
The rails came off the day before the Director of Rehabilitation spoke with inspectors — April 15, the day after inspectors first observed them on the resident's bed.
The unit manager who spoke with inspectors on April 15 offered a different explanation for why the rails had stayed. Resident 41 was "grandfathered in," they said. Therapy periodically asked whether the resident still used them. One rail had to be physically removed by maintenance every time the resident left for an appointment, then reinstalled when they returned. The unit manager wasn't sure whether maintenance checked the other rail during those visits. They also weren't sure whether routine assessments were required.
The Director of Maintenance told inspectors that bed rail inspections happened once a year and that entrapment zones were tested at that time. If nursing flagged a loose rail, it was tightened. The annual inspection, they noted, was due that month.
The Assistant Director of Nursing said she wasn't sure whether staff needed to re-educate the resident about risks and benefits on a routine basis, or only once before the rails were first installed. She knew a physician order was required. She did not know why one had never been reissued after the hospitalization.
What the inspection record shows is a facility where multiple departments knew the bed rails existed, knew the resident refused to give them up, and responded by doing less oversight rather than more. The therapy screens that were supposed to run quarterly went undone. The order that lapsed during a hospitalization was never renewed. The safety assessments that might have caught the entrapment risk were skipped for close to a year.
Resident 41 told inspectors they had used the rails for as long as they had been in the facility. They wanted to keep them. That preference was documented. What was not documented, for months at a stretch, was any formal evaluation of whether the rails were safe for a resident who, by the Director of Rehabilitation's own account, lacked the hand strength to protect themselves if something went wrong.
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.
They had kept the rails since arriving at the facility and wanted them.
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.