Van Duyn Center: Wound Care Failure for Diabetic Resident - NY
The resident, identified in inspection records as Resident #274, relied on a wound vacuum-assisted closure device, a specialized piece of equipment that promotes healing by applying continuous suction to a wound. When the primary wound care nurse was away, the device came off. The resident told inspectors they wheeled themselves around the hallway looking for someone who could reattach it.
Nobody could, or did.
The gap ran from February 6 to February 21, 2025. The wound care nurse who normally handled the resident, Registered Nurse #128, was off for those 10 days. She told inspectors she expected her colleague, Wound Care Registered Nurse #136, to monitor and consult on complex cases like Resident #274 in her absence.
Wound Care RN #136 told inspectors something different. She had not provided wound care to Resident #274 at any point during that period. She said she was not responsible for covering the other wound nurse's entire caseload.
The unit manager, Registered Nurse #9, acknowledged the documentation gap but told inspectors she was confident the care had been done anyway. It just wasn't written down. That explanation had a problem: the medication administration record showed the wound dressing was listed as "on," but there was no entry indicating it had actually been changed.
The Director of Nursing said all licensed practical nurses had completed wound vacuum competencies and were capable of providing the care. When the wound team was off, she said, it was communicated to the LPNs that they would be responsible. She said she had not been aware the dressing for Resident #274 had gone unchanged.
Licensed Practical Nurse #7 was more direct. Nursing staff had failed to document the resident's wound care during those 15 days, she told inspectors. She said following a wound care plan for a diabetic patient was critical, because the resident had already lost part of their foot, and failure to follow physician orders could result in the wound not healing.
That is the shape of what happened: a wound care nurse expected her colleague to cover. The colleague said that wasn't her job. The unit manager assumed someone else had done it. The Director of Nursing didn't know. The LPNs were told they were responsible but there is no record of them acting on it. And the resident, who told inspectors they had never even met the second wound care nurse, handled it themselves, packing the wound with gauze until someone came back.
Wound Care RN #128, when she returned and spoke with inspectors, described what she found on April 9. The wound was dry, without drainage or redness. She said she had expected continuity of care during her absence. She acknowledged there had been a lack of it.
The inspection, conducted by the New York State Department of Health on behalf of the Centers for Medicare and Medicaid Services, cited Van Duyn Center for failing to provide necessary care and services to maintain the highest practicable physical well-being of the resident. The deficiency was tagged at the level of actual harm.
Resident #274 told inspectors they relied heavily on Wound Care RN #128. They had never met the other wound care nurse. For 15 days, while the staff sorted out whose responsibility they were, they covered their own wound and waited.
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.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
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.
When the primary wound care nurse was away, the device came off.
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.