Van Duyn Center: Grooming Neglect, Matted Hair - NY
The back of the resident's hair, identified in inspection records as Resident #336, had become so matted that a certified nurse aide could not comb through it. A barber had come to the room at some point, told the resident they would return, and never did. No one followed up.
That was not the worst of what inspectors found.
Another resident, Resident #160, had intact cognition, meaning they understood exactly what was and was not being done for them. When a certified nurse aide finished what she described as a full round of care for the day, including brushing the resident's hair and teeth, the resident held up an electric toothbrush and said their teeth had not been brushed. The aide, identified as Certified Nurse Aide #169, told inspectors she was not sure why she had not washed the resident's hair or combed it.
She also could not locate the hairbrush. She said she had thrown away the toothbrush she used.
The aide acknowledged that the matted tangle of hair on Resident #160's head was actually worse before. At some earlier point, staff had cut out a chunk of hair entirely because it could not be combed through.
A second aide, Certified Nurse Aide #173, told inspectors that Resident #336 had asked for a haircut when the resident was on her assignment, at least two months prior. She knew the barber had come and gone without following through. She had not followed up either. "If a resident wanted to be groomed and was not," she told inspectors, "it could be a dignity issue."
The explanation for how oral care had slipped was offered without apparent alarm. Certified Nurse Aide #169 told inspectors that a lot of staff did not provide oral care because they had lost track of it over the years.
The Director of Nursing, interviewed on the afternoon of April 18, said hair should be brushed and oral care done every day unless a resident refused. Resident #160 had not refused. The Director acknowledged that if hair and teeth were not brushed, or showers not provided, it could make a resident feel down.
Resident #160 had intact cognition. They knew what was happening, or not happening, to their own body. They showed the aide the electric toothbrush themselves.
The inspection was conducted April 15 through April 18, 2025, at Van Duyn Center for Rehabilitation and Nursing, located at 5075 West Seneca Turnpike in Syracuse. The deficiency was cited under New York state health code and classified at the lower end of the harm scale, meaning inspectors determined the violations caused minimal harm or the potential for actual harm, and affected few residents.
That classification does not capture what it means to have a chunk of hair cut from your head because no one combed it. It does not account for a cognitively intact person holding up their own toothbrush to prove a point to the person who was supposed to care for them.
The Director of Nursing said care should follow the care plan and resident preference. Resident #336's preference had been documented for at least two months. The barber had come and gone. Staff had moved on to other assignments.
The resident's hair stayed matted.
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 27, 2026 · Our methodology
Van Duyn Center For Rehabilitation And Nursing in SYRACUSE, NY was cited for neglect violations during a health inspection on April 18, 2025.
The back of the resident's hair, identified in inspection records as Resident #336, had become so matted that a certified nurse aide could not comb through it.
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.