Van Duyn Center: Insulin Orders Missed at Admission - NY
The admitting nurse missed it.
The resident went without the sliding scale insulin. Nobody flagged the gap. The endocrinologist's team, according to the April 2025 inspection report, saw the resident multiple times during the hospital stay and was never notified by nursing staff at Van Duyn that there were blood sugar problems after admission. The inspection found that if a resident did not receive the insulin ordered by the endocrinologist, they could end up hyperglycemic.
Inspectors documented the lapse during a survey completed April 18, 2025.
The registered nurse who reviewed medications for newly admitted residents, identified in the report as RN #145, described what happened during an interview on April 16. The resident, listed as Resident #322, was a long-stay resident whose orders were reviewed with a nurse practitioner on the facility's longevity team. The discharge paperwork included a new tube feeding order and a standard sliding scale insulin coverage protocol. RN #145 said the nurse practitioner decided to discontinue the sliding scale because the resident was experiencing nausea and vomiting, and the decision was made to monitor fingerstick blood sugar readings alongside a long-acting insulin instead.
What the nurse practitioner ordered and what the endocrinologist had specified were not the same thing.
There was a second problem layered underneath the first. When blood sugar checks were scheduled after admission, they were timed to coincide with the resident's bolus tube feedings rather than before them. Blood sugar should be checked before a bolus feeding to get an accurate reading. The fingersticks, in other words, were being done at the wrong time even when they were being done at all.
The hospital's discharge orders had included an injection algorithm and two scales precisely because the resident's insulin needs would differ depending on whether they were receiving tube feedings. That nuance was gone. The admitting nurse, RN #145 explained, had called and reviewed the orders with the provider team, and the sliding scale was missed in that review.
The Director of Nursing, interviewed on April 18, said the facility's process required all orders to be reviewed for new admissions and that when a nurse called a provider, they were expected to go over all orders to finalize them. All medications, the Director said, were reviewed by providers, and it was ultimately the provider's decision what to order.
That framing places the responsibility on the nurse practitioner who made the call to discontinue the sliding scale. But the inspection report makes clear that the nurse practitioner was working from an incomplete picture, because the admitting nurse had already missed the sliding scale before the conversation with the provider team happened. The endocrinologist's instructions, written for this resident's specific condition, did not make it into the order review intact.
The deficiency was cited under New York State regulation 10 NYCRR 415.15(b)(2)(iii), which governs medication management for nursing home residents. The inspection classified the level of harm as minimal harm or potential for actual harm, with few residents affected.
Resident #322 was a long-stay resident at a facility that, by the Director of Nursing's own account, had a process designed to catch exactly this kind of error. The process did not catch it. The endocrinologist had seen the resident, written the orders, and sent the resident to Van Duyn with instructions in hand. Somewhere between the discharge paperwork and the first fingerstick, the sliding scale disappeared, and no one noticed until inspectors arrived.
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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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.
The resident went without the sliding scale insulin.
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.