Van Duyn Center: Deaf Residents Left Without Communication - NY
Federal inspectors rated what they found as immediate jeopardy, the most serious classification available under Medicare and Medicaid oversight, meaning the situation posed an immediate threat to resident health or safety.
The inspection, conducted in April 2025, documented the experiences of two residents, identified in the report as Resident #50 and Resident #162. Both were deaf. Both relied on American Sign Language. And for a stretch of time that stretched past what inspectors would accept, neither had reliable access to a way to make themselves understood.
The details that emerged from staff interviews are what make the record hard to read.
A certified nurse aide, interviewed on April 17, told inspectors that Resident #162 had a tablet of their own, kept in the resident's closet. It had always been there. But the aide wasn't sure whether staff knew how to use it. The tablet sat in the closet. The resident remained in a facility full of people who could not speak their language.
A unit clerk, interviewed the same afternoon, was more direct. Resident #162 preferred to use a tablet for interpreting or signing. There had not been a tablet available for interpreting before that week. Staff had been writing things down. They had been Googling signs. They had been told about a language line, a telephone-based interpreting service, but had not used it before that week either.
An LPN and unit manager, interviewed three minutes later, offered a third version. She said Resident #162 did not own a tablet and that the facility had provided one that week. The tablet had not been readily available before then.
Three staff members. Three different accounts of the same basic fact: whether a deaf resident had access to a device that could help them communicate. The nurse aide said the resident owned one but staff didn't know how to use it. The clerk said there was no tablet at all until that week. The unit manager said the facility provided one that week and that none had existed before.
What all three accounts agreed on was this: before the week of the inspection, Resident #162 had no reliable way to communicate with the people responsible for keeping them alive.
The inspection report notes that the resident's family also used American Sign Language and had depended on the facility to ensure the resident's needs were met. It does not say how long the resident had been at Van Duyn. It does not say what medical care they required, what decisions they needed to make, or what they tried to express during the weeks or months that staff were writing notes and searching the internet for signs.
Inspectors notified the facility of the immediate jeopardy finding on April 11, 2025, at 12:42 in the afternoon.
By 5:50 that evening, the facility had submitted an initial plan. It committed to providing both Resident #50 and Resident #162 with tablets programmed with a video relay interpreting service, kept in their rooms and always accessible. Staff and residents would be educated on how to use them.
The plan was approved. Then it failed.
By April 12, inspectors had determined that staff and residents were unable to use the tablet for communication. A second plan was required. It was approved just before midnight on April 12.
The facility then moved to educate its workforce. By April 16, 89.5 percent of staff had received in-service training on the communication devices. The remaining staff, those not currently on the schedule, were to be trained before their next shift. Inspectors visited on-site through April 16 and interviewed multiple staff members, who demonstrated knowledge of what they had been taught.
The immediate jeopardy was removed at 10:50 in the morning on April 16.
The violation was cited under New York State regulation 10 NYCRR 415.5(b)(1-3), which governs resident rights and the facility's obligations to meet residents' communication needs.
What the timeline reveals is a sequence that is difficult to explain. Resident #162 arrived at Van Duyn, deaf, relying on American Sign Language, with a family that communicated the same way. Somewhere in the process of admitting and caring for that person, the facility failed to establish a reliable communication system. Staff improvised with written notes and internet searches. A tablet may or may not have been in a closet. The language line existed but was never used.
The immediate jeopardy finding suggests inspectors believed this was not a minor gap. The classification exists for situations where the failure to act could cause serious injury, harm, impairment, or death. Applied here, it means inspectors concluded that a deaf resident's inability to communicate with caregivers rose to that level.
It is not difficult to understand why. A resident who cannot tell a nurse that something hurts, cannot ask what medication is being administered, cannot refuse a procedure, cannot report that another staff member has done something wrong, cannot say they are frightened or confused or in pain, is a resident whose safety depends entirely on staff noticing what they cannot say. That is a different kind of vulnerability than most nursing home residents face.
The unit manager's comment about Resident #162's vision adds another layer. The resident could see with or without glasses, the manager told inspectors, but it was more beneficial when they wore them. Their right eye was stronger. If staff used the right side, the resident could communicate more effectively. This was information the unit manager had. It is not clear when she learned it, or whether it had been in the resident's care plan, or whether the aides who cared for the resident day to day knew to position themselves on the right.
Van Duyn Center for Rehabilitation and Nursing sits on West Seneca Turnpike in Syracuse. It is a large facility. The inspection record covers only these two residents and this one violation category, but the immediate jeopardy designation means the state and federal agencies overseeing it had to be satisfied that the problem was genuinely corrected before the finding could be lifted.
The finding was lifted. The tablets are now programmed and in the residents' rooms. Nearly nine in ten staff members have been trained. The second plan, the one that replaced the first plan after the first plan didn't work, was approved and implemented.
Resident #162 can now, presumably, press a button and see a human face that speaks their language.
What they needed to say during the weeks before that tablet arrived, and whether anyone understood it, the inspection report does not say.
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.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 26, 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.
The inspection, conducted in April 2025, documented the experiences of two residents, identified in the report as Resident #50 and Resident #162.
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.