Van Duyn Center: Residents Lost Weight Without Supplements - NY
Federal inspectors who visited the facility on April 18, 2025, documented what happened when nursing home staff stopped checking whether residents received the meals and supplements ordered to keep them alive and gaining weight. Two residents, identified in inspection records as Resident #740 and Resident #306, had each experienced significant weight loss. Both had specific food and supplement orders in place. Both went without them, repeatedly, while staff on multiple levels either didn't notice or didn't act.
The certified nurse aide assigned to Resident #740's unit told inspectors on April 15 that she had never seen Magic Cups or supplements appear on that resident's meal trays. She wasn't sure whether the resident had lost weight. The dietetic technician knew. She told inspectors the resident had significant weight loss, that food preferences had been discussed, that yogurts and peanut butter and jelly pocket sandwiches had been added to the meal ticket. If those items weren't showing up on the tray, she said, it was not acceptable and could lead to further weight loss.
The registered dietitian who spoke with inspectors was equally direct. Resident #740's soup and yogurts were the resident's own choices, she said, and they assisted in maintaining weight. It was unacceptable for the resident not to receive them. She said the same about Resident #306, who had been ordered fortified juice as a supplement, with Ensure clear designated as the substitute if the juice wasn't available. The director of dietary services confirmed there was a substitution list in the kitchen for exactly that situation.
The facility knew it had a supply problem. A national recall had pulled fortified cran-apple juice from the shelves, and Van Duyn didn't have it. The protocol was clear: substitute fortified orange juice, or Ensure Plus. Whether that substitution actually reached Resident #306's tray, inspectors found, was another matter.
The nurse practitioner who saw Resident #740 told inspectors the resident should have been receiving Ensure and fortified foods at every meal. If preferred items were missing from the tray, she said, it was not acceptable. The resident had lost significant weight. The preferred foods were there to prevent further loss.
What the inspection record shows is a gap between what every staff member knew and what actually happened at the tray level. The dietitian knew the protocol. The nurse practitioner knew the stakes. The dietary director knew about the recall and the substitution list. The dietetic technician had added the preferred items to the meal ticket herself. And the aide who handed Resident #740 their meals day after day had never once seen a supplement on the tray.
The registered dietitian told inspectors that dietary staff and certified nurse aides were both responsible for checking meal trays for accuracy and notifying her if an item was not available. The director of dietary services said the same thing: dietary aides and certified nurse aides were responsible for meal ticket accuracy.
Neither Resident #740 nor Resident #306 had been seen by a physician regarding their weight loss, according to the inspection record. Resident #740 told inspectors directly: the food preferences had been discussed with staff, but the food never showed up on their trays, and no doctor had come to talk about what was happening to their weight.
The facility received a deficiency citation under New York state nutrition regulations. Inspectors rated the level of harm as minimal harm or potential for actual harm, affecting few residents.
Resident #740 already had significant weight loss by the time inspectors arrived. The yogurt and the soup, small enough requests, were still not reliably on the tray.
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 violations during a health inspection on April 18, 2025.
Two residents, identified in inspection records as Resident #740 and Resident #306, had each experienced significant weight loss.
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.