Syracuse nursing home horror: Death, unwashed residents, expired drugs, bad food

(Editor’s note: An earlier version of this story contained a wrong date due to inaccurate information provided by the state Department of Health. Government payments were stopped for new admissions on Aug. 16, not May 11.)

Syracuse, N.Y. – A Van Duyn nursing home resident died in November of a serious complication of diabetes after nurses failed to tell a doctor the person’s blood sugar levels were dangerously high.

Another resident lost 24 pounds, or about 21% of body weight, in two months because Van Duyn did not get the individual a feeding tube or let the resident’s family bring in special meals.

Those are the most serious deficiencies among a lengthy list of problems uncovered during two recent inspections of the 513-bed Onondaga Hill facility.

Inspectors also found some residents unwashed and not dressed, expired medications, workers wearing face masks below their noses and an immobile 700-pound resident who could not be evacuated if a fire broke out.

An inspector saw a nurse aide spilling food all over a blind resident who needed help eating. And the nursing home’s food service director admitted an overcooked, lukewarm hamburger served at lunch was unacceptable.

The federal government cut off Medicare and Medicaid payments to Van Duyn for new admissions Aug. 16 because of infection control violations uncovered in a June 21 inspection. That payment denial will remain in effect until a follow-up inspection shows those problems have been fixed, according to the Centers for Medicare & Medicaid Services. The government also fined Van Duyn $31,335.

Denial of payments for new admissions is a relatively rare enforcement action taken against nursing homes. Just 11 of New York’s 617 nursing homes and 701 of the nation’s 15,600 nursing homes have had payments denied for new admissions in the federal fiscal year that ends Sept. 30, according to the Centers for Medicare & Medicaid Services.

“It’s a very serious penalty suggesting there are very big concerns with quality of care,” said Nina Kohn, a Syracuse University law professor and expert in elder law. | The Post-Standard obtained copies of the reports from the federal Centers for Medicare & Medicaid Services. The state Health Department conducted the inspections May 11 and June 21 on behalf of the federal agency.

Patrick Calli, Van Duyn’s administrator, said in a prepared statement the nursing home believes some of the inspection findings are inaccurate and is disputing them. He did not specify which ones.

“The survey results were not what our team hoped for, however in light of the global pandemic and its impact on the labor market across all industries, our team did the best we possibly could. The entire healthcare system continues to navigate the difficulties caused by the ongoing pandemic,” he said.

Poor care at Van Duyn has been a problem for more than a decade. The federal government rates nursing homes on a scale of one to five stars. Van Duyn gets one star, the lowest rating which means much below average.

An 84-year-old woman was found dead there Dec. 13 after she fell and accidentally hanged herself when her hospital gown got caught on a bathroom door handle. She needed assistance getting to and from the bathroom, but staff did not help her.

The nursing home has been cited for not having enough nurses and certified nurse aides to care for residents and administer drugs. It’s also been cited for abuse. An aide purposely pushed a resident’s wheelchair into a wall in 2019, injuring the resident’s leg. The nursing home was cited in 2018 for letting the body of a deceased resident decompose in a morgue where the temperature was more than 80 degrees.

Van Duyn was named one of the nation’s worst-performing nursing homes in 2011 when it was owned by Onondaga County. Upstate Services Group, a for-profit company, bought Van Duyn in 2013 and has repeatedly promised to improve the facility. But inspection reports show the facility is still dogged by persistent problems. Van Duyn’s majority owners are Uri Koenig, an accountant, and Efraim Steif, a nursing home administrator, both of Rockland County. Upstate Services operates 11 other nursing homes in New York, including Central Park Rehabilitation and Nursing Center in Syracuse.

Medicare is the federal health insurance program for people 65 and older, and people with disabilities.

The loss of Medicare payments for new admissions could put a crimp in Van Duyn’s finances. The nursing home received about $3 million in Medicare payments in 2018, according to the most recent data available from the Centers for Medicare & Medicaid. It received $20 million in Medicaid payments in 2019, according to the most recent data available from the state Health Department.

Medicare pays for short-term rehabilitation care in nursing homes for patients after they are discharged from hospitals. Medicaid, the joint federal-state health insurance program for low-income people, pays for long-term nursing home care for people with limited income.

The May 11 inspection report does not identify the diabetic resident who died. Van Duyn sent the resident to a hospital Nov. 28, sweating heavily and unresponsive.

The day before, the resident was given insulin after a finger prick test showed the individual’s blood sugar levels were very high. Nurses failed to check the resident’s blood sugar levels again after each meal that day to determine if more insulin was necessary, the report shows.

On the morning of Nov. 28, two more tests showed the resident’s blood sugar levels were still too high. But staff did not contact a doctor to provide more treatment, the inspection says.

The resident died the next day in the hospital of ketoacidosis, a dangerous condition that occurs when the body cannot make enough insulin, according to the report.

An inspector categorized Van Duyn’s mishandling of that case and the case involving the resident who experienced the rapid weight loss as “actual harm.” That’s the second most serious type of nursing home deficiency that results in a “negative outcome” for residents.

Van Duyn also was cited for failing to keep the facility free of accident hazards. The inspection found the nursing home did not have a plan on how to evacuate an immobile 700-pound resident confined to bed in the event of an emergency.

The resident’s bed is 52 inches wide, but the doorway of the person’s room is only 45 inches wide.

Several staffers interviewed by the inspector said they had not been trained how to evacuate obese residents.

The nursing home has two 34-inch wide bariatric wheelchairs currently in use. Van Duyn’s director of central supply told the inspector if a larger custom wheelchair is needed the nursing home would have to buy one.

Since the Covid-19 pandemic began last year, the state has required nursing home workers to wear face masks when they are within six feet of residents.

An inspector spotted four Van Duyn employees in June within six feet of residents wearing masks below their nose or chin.

Only 55.4% of Van Duyn workers had been vaccinated against Covid-19 as of Aug. 17, the lowest rate of any nursing home in Onondaga County. Covid-19 has killed 54 Van Duyn residents since the pandemic began.

In response to the latest surge in Covid-19 delta variant infections, the state recently ordered all health care workers, including nursing home staff, to get vaccinated by Sept. 27. President Biden on Wednesday warned that the federal government will cut off funding to nursing homes that don’t get all their workers vaccinated.

The June 21 inspection showed some areas of the building were unkempt. The inspection found rusty hand wash sinks, a shower room with a hole in the ceiling, a broken electrical outlet with exposed metal in a resident’s room, a wheelchair in the hallway with a brown stain on the seat and a bed missing a side support rail.

An oven in Van Duyn’s main kitchen was broken for three months. A kitchen steamer and garbage disposal also were out of order. A kitchenette had no electric power for two weeks, leaving a coffee maker, toaster, microwave and steam table inoperable.

An inspector also saw cockroaches in the main kitchen and two kitchenettes.

Federal law requires nursing homes to provide residents with food that tastes and looks good, and is served at the correct temperatures. Some Van Duyn residents told the inspector the food was terrible and usually lukewarm.

The inspector checked the food on a lunch tray and found an overcooked, dry hamburger and mashed potatoes that were not hot. The nursing home’s food service director acknowledged the food on the lunch tray was unpalatable and served at the wrong temperatures.

Federal law says nursing homes must treat residents with respect and dignity. The June 11 inspection, however, found some Van Duyn residents are afforded little dignity.

The inspector saw some residents dressed in nothing but gowns or no clothes at all. One resident was observed sitting on the side of his bed wearing a hospital gown with his genitals exposed. Others were unshaven with greasy hair, and long dirty fingernails.

One resident told the inspector every time he asked staff for a shave or to clean and trim his nails, he was told to wait until tomorrow.

The resident also said he had not brushed his teeth in two weeks. The inspector checked the bathroom in the man’s room and discovered there was no toothbrush or toothpaste.

An inspector observed an aide wearing airpods while feeding a resident. Because of the airpods, the aide could not hear the inspector say “hello” or knock on the door. Staffers are not supposed to use airpods or cell phones while working.

A manager said aides are supposed to sit down and converse with residents while feeding them and give them clothing protectors to protect from any spills.

But an inspector saw an aide standing over a blind resident while feeding the person. The aide spilled forkfuls of food on the resident’s shirt and admonished the resident.

“You just asked me to help you and you are trying to take the fork and talking,” the aide said. “I can’t do three things at once.”

James T. Mulder covers health and higher education. Have a news tip? Contact him at (315) 470-2245 or

If you are a Van Duyn resident or have a loved one who lives there, we would like to hear about your experience. Please contact Michelle Breidenbach at or 315-470-3186.