Years of Screaming: Van Duyn Center and the Community That Could Not Get Anyone to Listen
SYRACUSE, NY. Sandra Young came to Van Duyn Center for Rehabilitation and Nursing to get better. She had just lost a leg. The plan was rehabilitation, then home.
She never left.
Her sister, Alice Young, watched staff ignore Sandra's medical complaints. Watched them fail to provide consistent therapy. Watched them leave Sandra waiting for help that did not come. Then one day, Sandra stopped waiting. She called 911 herself. Paramedics found her with a kidney infection and 35 pounds of excess fluid in her body.
"If she would not have been able to speak for herself," Alice Young told CNYCentral.com, "God knows what would have happened to her."
Sandra could speak for herself. Not everyone at Van Duyn can. And according to the New York Attorney General's Office, at least one resident who could not died because of it.
What the Attorney General Found
In August 2025, New York Attorney General Letitia James announced a $12 million settlement with Van Duyn's owners, Efraim Steif and Uri Koenig. The findings documented in that settlement go beyond the inspection violations that had already been on public record for years.
A resident died after staff failed to assist her to the bathroom. She fell. Her nightgown caught on a door handle. She strangled to death.
A second resident was found deceased in rigor mortis after what the AG described as inadequate care and medication management. Multiple residents were inappropriately discharged from the facility and abandoned at a Department of Social Services office.
Another resident was hospitalized for untreated glucose problems. Another was admitted to the hospital with a bacterial infection, bed sores, and dehydration.
While residents were dying from neglect, the AG found that Steif and Koenig were draining the facility financially. From 2015 through 2022, the owners withdrew tens of millions of dollars through fraudulent inflated rental payments. They transferred more than $2 million to themselves as unearned salaries. The facility's residents were being warehoused while its owners extracted money that should have paid for their care.
"We are holding Van Duyn's owners accountable for these conditions, ensuring the facility makes necessary changes so residents get deserved care," Attorney General James said.
The settlement required $2 million in restitution to New York's Medicaid program and $10 million to a Resident Care Fund for facility improvements. An independent health care monitor was appointed with authority to impose $5,000-per-day penalties for non-compliance. An independent financial monitor was appointed to prevent further fraud. The owners were required to hire a Chief Compliance Officer. And Steif and Koenig were prohibited from closing or selling the facility for five years.
The prohibition on selling is significant. It means the owners cannot exit the situation they created. They are legally required to fix it.
Seven months after the settlement, federal inspectors returned and found two categories of Immediate Jeopardy.
What the Community Calls It
People in Syracuse have a name for Van Duyn Center. They call it Van Doom.
The nickname is not new. It circulates through hospital waiting rooms and family conversations and, more recently, across hundreds of Facebook comments from people who watched the same pattern play out with their own fathers, mothers, siblings, and grandparents. Some have been raising alarms for years. Some for decades.
"There are 1,000s of us in the community who have been saying how bad it's been for years and no one ever listens," wrote Lindsey Stroup-Riehle publicly in response to CNYCentral.com's May 2026 coverage. Nella Mattice placed her father there ten years ago. She watched him slumping unconscious in his wheelchair in the common area, drooling, while staff did nothing. She complained. Nobody helped. She eventually got him out. "We complained and nobody would help," she wrote. "That's just one instance."
A 2024 investigation by NCC News at Syracuse University's Newhouse School, which dug into four years of public records, reached the same conclusion years before the AG settlement: the problems at Van Duyn were systemic, documented, and ignored.
Now, after years of public complaints, multiple rounds of local television coverage, the AG settlement, and a federal designation that identifies Van Duyn as one of the most troubled nursing homes in the country, the facility's 513 residents remain inside. The community is still screaming. The difference, in the spring of 2026, is that the federal inspection record confirms what they have been saying all along.
The Federal Record
Van Duyn Center for Rehabilitation and Nursing, operated as a for-profit limited liability company in Syracuse, holds the federal designation of Special Focus Facility. CNYCentral.com reported Van Duyn's addition to that list in December 2025. The Centers for Medicare and Medicaid Services applies the Special Focus designation to nursing homes with persistent, documented histories of serious quality problems. Van Duyn's CMS overall rating, health inspection rating, staffing rating, and quality rating are all zero, the lowest designation the agency records.
The New York State Department of Health cited Van Duyn 56 times for standard health violations between 2021 and 2025, nearly three times the statewide average. Those citations covered infection control failures, neglect, inadequate supervision, and failures to protect residents from harm. CNYCentral.com's earlier reporting on those state findings laid out the pattern in detail.
A 2022 investigation by NCC News at Syracuse University's Newhouse School documented 315 complaints filed against Van Duyn between April 2018 and March 2022. That translates to 68.8 complaints per 100 occupied beds. The statewide average for New York nursing homes was 49.9. During that same period, the state issued 78 citations across 20 inspections.
The specific violations documented during those inspections trace a pattern of failures in the same categories, repeated across multiple years. In October 2020, state inspectors cited Van Duyn for failing to report a sexual incident between two residents to the health department within the required timeframe. In November 2020, 19 residents did not receive proper medication. In August 2021, inspectors cited the facility for failing to complete required neurological checks on a resident who had fallen. That resident was later found dead, in full rigor mortis, two hours after the last documented check.
Federal inspection data maintained by NursingHomeNews.org shows the arc of what inspectors have found across multiple visits spanning nearly a decade. A January 2017 inspection produced 23 deficiencies. A June 2021 inspection produced 19. A July 2023 inspection produced 15. CMS assessed financial penalties against the facility in 2017, 2020, and 2021, totaling $47,866 in federal fines, separate from the state AG settlement.
The April 18, 2025 inspection produced 27 deficiencies. The highest single-visit total in the facility's recent history.
April 2025: Two Categories of Immediate Jeopardy
Of the 27 deficiencies cited during the April 2025 inspection, two carried a scope and severity code of K. In the federal nursing home rating system, K indicates a pattern of violations that inspectors determined created an Immediate Jeopardy to resident health and safety. It is among the most serious designations CMS issues. Finding two of them in a single inspection, in two separate categories of care, is not a routine finding.
The first K-level citation covered federal tag F0880, governing infection prevention and control. The second covered F0561, governing resident self-determination, the right of residents to make informed decisions about their own care. A citation at the pattern plus Immediate Jeopardy level means inspectors found not an isolated failure but a repeated practice that placed residents at immediate serious risk.
A third deficiency, F0550 covering resident dignity and rights, was cited at level H: a pattern of violations that caused documented Actual Harm to residents, not merely risk of harm.
F0684, covering treatment and care according to physician orders and resident preferences, was cited at level G: isolated, Actual Harm. A resident was harmed because prescribed care was not delivered.
Three months earlier, in January 2025, federal inspectors had cited F0600, protecting residents from abuse, at level G: isolated, Actual Harm.
This was not a facility approaching a threshold. This was a facility where, in a single inspection, federal inspectors documented two categories of immediate jeopardy, a pattern of harm to resident dignity, and multiple instances of care failures that injured specific residents. Seven months after a $12 million settlement was supposed to fix it.
The Pest Problem That Survived Four Years and Three Inspections
Federal tag F0925 requires nursing homes to maintain pest control programs to prevent and address mice, insects, and other pests.
Van Duyn was cited under F0925 in June 2021.
Inspectors cited F0925 again in October 2023.
In April 2025, inspectors cited it again.
Three separate inspection cycles. Four years. The same violation, unresolved, each time inspectors returned to check.
A former employee who spoke to CNYCentral.com described a roach infestation so severe that a white wall appeared black from their density. She described mice entering patients' beds. These are not conditions that develop between inspections. They are conditions that persist because nobody fixes them, and the federal record confirms they persisted through at least three separate rounds of regulatory scrutiny.
Inside the Building
The former employee came forward anonymously in May 2026, with her voice altered on camera, citing fear of retaliation. She had started documenting conditions during her second week on the job.
"The level of hell that is present at Van Duyn at any given day," she told CNYCentral.com, "Dante's Inferno doesn't even begin to describe."
She described residents going untouched across two full staff shifts. Not bathed. Not dressed. Not moved. She described the mice and the roaches. She described overflowing trash, urine on the floors, and residents left waiting, with photographs to document what she saw.
Her framework for the facility was direct. "My understanding of Van Duyn is a prison," she said. "While the CNAs are the correctional officers."
"Prisoners get better treatment than senior citizens," she added. "Some of them don't have families, don't have a way to reach out or any way out of there, so they are just stuck there."
Alice Young said almost the same thing in a separate interview. "There are a lot of people in that place that are suffering. A lot of them that don't have family members and friends that come and visit them, and some a lot of them that can't even advocate for themselves."
Two people, one who worked inside and one whose sister was a resident, describing the same condition independently: people with no one to speak for them, with no way out.
The Families
The accounts that surfaced in response to CNYCentral.com's May 2026 reporting represent years, in some cases decades, of experience with Van Duyn. Across dozens of public responses, the details are consistent: emergencies ignored, retaliation against residents who complained, family members told to wait while their loved ones deteriorated.
Patricia Ward went to Van Duyn specifically for physical therapy following complications from liver surgery. The Newhouse School investigation found the therapy itself was competent. The nursing care was not. Ward was left in unchanged diapers for hours at a stretch. Once, she told NCC News reporters, she waited seven hours. Her daughter, Mary May, fielded nightly calls from her mother in tears, unable to sleep for fear of missing an emergency call. When May raised complaints with the facility staff, an aide retaliated against her mother directly. "I could hear this aide yelling at my mother," May said. "That she was a bother." May kept calling, kept filling out complaint forms. It took a week and a half for anyone to respond.
Kasey Emma's father entered Van Duyn with broken bones from a fall, a healthy man when he arrived. He left with both legs amputated. The first amputation, she wrote publicly, resulted from negligence following surgery. A second followed two months later. Between surgeries, he fell in the bathroom and struck his head on the sink because he was left to manage on his own. "Almost didn't leave at all," she wrote.
Jenn Spadotto's brother was placed at Van Duyn after brain surgery. The toilet in his room was clogged. Staff made him plunge it himself. His pain medications disappeared. His food disappeared. His family bought toilet paper because the facility did not supply it. Spadotto cleaned his room every visit. She called the New York State Department of Health. She was told they were "well aware" of the facility and had received thousands of complaints before hers. Her brother was at Van Duyn for 11 days. He died at 43.
Sarah Plaza's grandmother asked staff for better care. In response, Plaza said publicly, a staff member pushed her grandmother out of bed. The wound required 15 stitches and 30 staples. When Plaza called the facility for answers, she was hung up on. She called back. She was told not to call again.
Betsy Farr was transferred to Van Duyn by Upstate Community Hospital without, she said, her informed consent. She arrived already sick. Within a day she had a confirmed diagnosis of pneumonia and a 101-degree fever. Staff required her to complete physical therapy regardless. When she told staff she wanted to go home and continue rehab as an outpatient, she was told that leaving against medical advice would prevent her from being admitted to any other facility. She stayed for five weeks.
Kim Singleton's mother was found on the floor after a fall with a blood sugar of 30. Singleton called for an ambulance. Staff told her that passing out meal trays was the priority. Singleton called 911 herself.
Some families took their cases to court. Leonard Casciano arrived at Van Duyn on April 22, 2021, transferred from Crouse Hospital after a 22-day rehabilitation stay was approved. He was from East Syracuse. His condition required a high-calorie diet to manage his elevated metabolic rate. According to a wrongful death lawsuit filed by his family, Van Duyn gave him a regular diet instead. His room phone was broken throughout his stay, cutting him off from his sister, who was his legal guardian. He weighed 134 pounds at admission. He died on May 6, 2021, fourteen days after arriving. At autopsy, he weighed 110 pounds. The AG's investigation later identified his case as one of at least 24 cases of neglect under investigation at Van Duyn. Seven of those 24 residents died.
These are not accounts of minor dissatisfaction. They are accounts of medical crises ignored, a man who died at 43 after 11 days in a facility where the state health department had already logged thousands of complaints, and a resident pushed out of bed for asking for better treatment. They are consistent, across multiple families, across multiple years, with what the AG's investigation found: a facility where residents were harmed and neglected while its owners extracted money.
When It Changed: The 2013 Sale
Van Duyn Center was not always a for-profit limited liability company. Onondaga County owned and operated it.
It was already in crisis before it left public hands. In 2011, the federal government named Van Duyn one of the worst nursing homes in the nation. The county owned it at the time. The designation was not a surprise inspection anomaly. It was a documented reckoning with years of accumulated problems. The county responded by promising to improve the facility, then selling it.
In 2013, Onondaga County sold Van Duyn to a private operator called Upstate Services Group.
Jen Ryan, who commented publicly on CNYCentral.com's coverage, described the decision plainly: "The first problem is Onondaga County and the DOH allowing the facility to be sold to a FOR PROFIT organization in 2012. Did we honestly expect a FOR PROFIT to prioritize anything other than profit?"
The AG's findings give that question a specific answer. Efraim Steif and Uri Koenig did not prioritize care. From 2015 through 2022, they pulled tens of millions out of the facility through fraudulent inflated rental payments. They paid themselves more than $2 million in unearned salaries. The money that should have paid for adequate staffing, clean conditions, pest control, and functioning bathrooms was flowing to the owners instead.
The fines appeared in the federal record starting in 2017. The inspection deficiencies accumulated through 2021, 2023, and 2025. The problems did not begin on the day of the sale. Van Duyn was already one of the worst facilities in the country when the county handed it to private owners. But the financial extraction that the AG documented ran through the entire period of for-profit ownership, and the conditions that inspectors kept finding are consistent with a facility whose resources were being systematically drained.
The $12 Million That Did Not Fix It
The August 2025 AG settlement was the most substantial enforcement action Van Duyn had faced. Twelve million dollars. An independent health care monitor. An independent financial monitor. A Chief Compliance Officer. A $5,000-per-day penalty for non-compliance. A five-year prohibition on selling the facility. Spectrum News covered the settlement as a significant enforcement milestone.
The April 2025 inspection still found two Immediate Jeopardy violations.
The pest infestation that had been cited four years earlier was still there.
A pattern of harm to resident dignity. A resident harmed by failure to follow physician orders. A resident harmed in an abuse-related incident three months before the inspection.
The money was designated. The monitors were appointed. The April 2025 inspection returned findings that, in several categories, were more serious than anything in the years before the settlement.
The Oversight That Did Not Work
New York State maintains a Long-Term Care Ombudsman Program designed to investigate complaints from nursing home residents and their families. Tracy Reece offered a one-sentence assessment based on her own experience with Van Duyn: "Phone calls to [the] Ombudsman do nothing."
Jenn Spadotto went further than a phone call. She contacted the New York State Department of Health directly, reported what her brother had experienced, and was told the department was "well aware" of the facility and had already received thousands of complaints. That awareness had not triggered action sufficient to prevent the conditions she witnessed when her brother arrived. It had not prevented the three pest control citations. It had not prevented the deaths the AG documented. It had not prevented the two Immediate Jeopardy findings in April 2025.
Ryan Wallace put it publicly: "Pay taxes into state agencies that will sit back and do nothing anyway. Ask me how I know."
Rep. John Mannion pressed the issue further up the chain. CNYCentral.com reported that Mannion urged CMS to address the serious deficiencies at Van Duyn, and that CMS responded to his call. Even a congressional intervention produced a response letter, not a closure.
The oversight structure exists at every level: state ombudsman, NYSDOH, CMS, the AG's office, Congress. Every level has engaged with Van Duyn. The facility is still open. The residents are still inside.
513 Beds
Van Duyn is not a small facility. With 513 certified beds, it is one of the largest nursing homes in upstate New York. That scale matters. Every complaint documented here, every inspection finding, every account of ignored emergencies, retaliation, stolen medications, and residents left unbathed for two shifts, takes place in a building designed to hold more than 500 people.
Many of those 500 people, the former employee and Alice Young both said it independently, have no one coming to visit. No one to call 911 when staff won't. No one to escalate when the toilet stays clogged, when the wall turns black, when a resident has not been moved in two days.
"People screaming, help, help!" Alice Young told CNYCentral.com. "I cried. I literally cried because it's like, I know that, you know, there's only so much you can do."
A video shared with CNYCentral.com captured those cries. A voice on the recording: "Please help me."
Van Duyn administration did not respond to requests for comment.
What Accountability Looks Like From the Outside
Lisa Campbell, a nurse with more than 20 years in healthcare, described what she sees as a structural problem extending beyond Van Duyn: "Administration and CEOs aren't taking any pay cuts. They are getting bonuses for running their floors with minimal staffing. With the lack of housekeeping the floors end up a cesspool of diseases. This is mismanagement of funds and abuse. Fire the administration and get rid of the people who don't care. It's called accountability. There is none anymore."
Accountability is the word that keeps appearing across dozens of public responses. Not requests for symbolic action or press releases about settlement money. Requests for someone to be held responsible for specific outcomes: a man who died at 43, a woman with 30 staples in her leg, a resident who called 911 because staff would not, a woman who strangled to death because nobody helped her to the bathroom.
"This is nothing new," Jenn Spadotto wrote. "We have been saying it all along."
She is right. The pest control violation first appeared in 2021. The dignity and rights violations appeared in 2021 and again in 2023 and again in 2025. The owners were extracting money from the facility from 2015 through at least 2022. The pattern documented across nearly a decade of inspection data and confirmed by the AG's investigation is not the product of a sudden failure. It is the product of conditions that persisted through fines, settlements, admissions freezes, congressional inquiries, and rounds of media coverage without the underlying accountability that would change them.
Sandra Young's sister called 911 herself. Jenn Spadotto's brother died at 43. A resident strangled on a door handle because nobody helped her to the bathroom. The voice on the video said please help me.
Van Duyn Center for Rehabilitation and Nursing has 513 beds. The facility is still open.
A Note on Sources and What This Article Does Not Establish
Personal accounts in this article were shared publicly in comments on CNYCentral's Facebook page in response to their May 2026 reporting, or provided directly in on-camera interviews to CNYCentral.com journalists Rachel Culver and Gary Robinson Jr. NursingHomeNews.org has not independently verified every detail of each account. They are reported as stated by the individuals who shared them publicly.
Federal inspection data is drawn from records maintained by the Centers for Medicare and Medicaid Services and the NursingHomeNews.org inspection database. Penalty totals reflect CMS financial penalty records for federal provider number 335184. The AG settlement details are drawn from the official AG press release published August 25, 2025. Complaint statistics, the account of Patricia Ward and Mary May, and specific 2020-2021 inspection incidents are drawn from "Home and Held Hostage," an investigation by Imani Clement published June 2, 2022, by NCC News at Syracuse University's S.I. Newhouse School of Public Communications. The wrongful death lawsuit filed by the family of Leonard Casciano was first reported by WSYR-TV (LocalSYR.com).
This article does not establish criminal liability for any harm described. It does not determine the cause of any individual's death or injury beyond what is stated in the AG's findings. What the federal inspection record and AG settlement establish, alongside the consistent public accounts of families across multiple years, is a documented pattern of repeated serious violations at a 513-bed facility that has been the subject of community complaint for decades and continues to operate with zero ratings in every category CMS measures.
Federal inspection records for Van Duyn Center for Rehabilitation and Nursing, federal provider number 335184, are publicly available at medicare.gov/care-compare. The facility's full inspection history, penalty record, and staffing data are accessible there to any family currently monitoring or considering placement of a loved one.
If you have had a family member at Van Duyn Center and want to share your experience, NursingHomeNews.org can be reached through the contact form on this site. You may remain anonymous.