Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Grand Rehabilitation And Nursing At Great Neck during CMS and state inspections, most recent first.
A resident with dementia exhibited a behavior of wrapping tissues and rubber bands around their fingers, which was not addressed in their care plan. Despite multiple observations of this behavior, the facility failed to update the resident's comprehensive care plan. Staff interviews revealed a lack of communication and documentation regarding the behavior, highlighting a deficiency in the facility's care planning process.
A resident admitted after a pacemaker implantation did not have their pacemaker monitoring device set up for data transmission until three days post-admission, and a physician's order for monitoring was delayed by seven days. The nurse responsible for the admission was unaware of the need to set up the device, leading to a lack of data transmission to the resident's physician. The facility lacked a policy for pacemaker monitoring setup, resulting in assumptions that devices were pre-configured.
A resident with limited mobility did not receive the recommended floor ambulation program due to a lack of communication and documentation between the rehabilitation and nursing staff. The resident, who had moderate cognitive impairment and difficulty walking, expressed a desire to walk more but was unable to do so after their therapy ended. Staff interviews revealed confusion and a lack of awareness about the resident's ambulation program, resulting in the program not being consistently implemented.
A resident with dementia and incontinence was found in a urine-soaked brief due to delayed care. The CNA responsible did not report the resident's refusal of care, violating facility policy. The facility's policy required residents to be checked every two hours, which was not followed, leading to a deficiency in preventing urinary tract infections.
A resident with a tracheostomy was observed receiving 6 liters of oxygen per minute instead of the prescribed 4 liters, as per physician's orders. This discrepancy was noted on multiple occasions, and interviews with nursing staff revealed a failure to adhere to the facility's policy and physician's orders regarding oxygen therapy monitoring and adjustment.
A resident receiving Vancomycin for MRSA did not have a timely Vancomycin trough level test conducted as ordered. The test, crucial for monitoring therapeutic dosage, was not collected on the specified date, and nursing staff failed to follow up. The DON acknowledged the oversight, and the lab technician did not see the order, indicating a possible processing issue.
A resident with Pseudomonas Aeruginosa in the urine required Strict Contact Precautions, including PPE use. An LPN entered the resident's room without wearing a gown and gloves, misunderstanding the PPE requirement. The RN Infection Preventionist and DON confirmed the need for PPE, indicating a lapse in infection control adherence.
A resident's medical records were incomplete after a family member reported bruising on the resident's eye. The DON assessed the discoloration as a birthmark but did not document the assessment or communication. The Physician Assistant also evaluated the resident and found no trauma but did not document the findings, considering it a verbal concern. The facility's policy requires documentation of such assessments, which was not followed.
Failure to Update Care Plan for Resident's Behavioral Symptoms
Penalty
Summary
The facility failed to ensure that a comprehensive person-centered care plan was reviewed and revised by the interdisciplinary team after each assessment for a resident with behavioral symptoms. Specifically, the care plan for a resident with dementia and other diagnoses did not address the resident's behavior of wrapping tissues and rubber bands around their fingers. This behavior was observed on multiple occasions during the survey, yet the care plan remained unchanged. The resident, who had moderate cognitive impairment, was observed with tissues and rubber bands wrapped around their fingers on several occasions. The resident reported that they wrapped their fingers because facility staff had cut their fingernails too short, causing discomfort. Despite these observations, there were no updates or revisions made to the resident's comprehensive care plans to address this behavior. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's behavior. The Registered Nurse Manager acknowledged that the behavior should have been documented and the care plan updated. The Director of Nursing Services was unaware of the behavior and stated that it should have been monitored and documented. The Certified Nursing Assistant admitted to seeing the resident with wrapped fingers but did not report it to the nurse, indicating a breakdown in the facility's process for addressing and documenting resident behaviors.
Failure to Initiate Pacemaker Monitoring
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, specifically regarding the setup and monitoring of a pacemaker device. Resident #260, who was admitted after a Micra Leadless Pacemaker Implantation, required remote monitoring of the pacemaker. However, the facility did not initiate this monitoring until three days after admission, and there was no documented physician order for the monitoring until seven days post-admission. This delay in setting up the pacemaker monitoring device meant that the resident's cardiac data was not transmitted to their physician as required. Upon admission, Registered Nurse #1 was responsible for the intake of Resident #260 and noted that the pacemaker monitoring device was present. However, the nurse only plugged the device into the wall and did not set it up to transmit data, as they were unaware of the need for setup. It was not until 7/11/2024 that the nurse read the setup instructions and realized the device had not been transmitting data. The resident expressed concern about the lack of monitoring, which was confirmed by the nurse's admission of not verifying the transmission with the physician. Interviews with the Director of Nursing Services and the Cardiac Clinic's nurse revealed that the facility lacked a policy for setting up pacemaker monitoring devices, leading to assumptions that the devices were pre-configured. The Director of Nursing acknowledged the oversight and the absence of a physician's order for the monitoring device, which was only entered after the surveyor's intervention. This deficiency highlights a gap in the facility's admission procedures and communication with external medical providers.
Failure to Implement Recommended Ambulation Program
Penalty
Summary
The facility failed to ensure that a resident with limited mobility received the appropriate services and assistance to maintain or improve mobility. This deficiency was identified during a recertification survey for a resident who was recommended for a floor ambulation program by the Rehabilitation Department. Despite the recommendation, the program was not consistently implemented, as evidenced by the resident's Certified Nursing Assistant (CNA) Accountability Record, which showed that the program was only performed on eight out of ten opportunities. The resident, who had diagnoses including Non-Alzheimer's Dementia, Difficulty in Walking, and Congestive Heart Failure, expressed a desire to walk more but was unable to do so because their rehabilitation therapy had ended. Interviews with staff revealed a lack of awareness and execution of the floor ambulation program. The CNAs responsible for the resident's care admitted to not performing the ambulation task, and there was confusion among staff about whether the resident was still attending rehabilitation therapy. The Director of Rehabilitation and the Director of Nursing Services acknowledged a disconnect between the nursing and rehabilitation staff regarding the resident's floor ambulation program. The Director of Rehabilitation could not provide documentation of the education provided to the nursing staff about the program, and the Director of Nursing Services confirmed that CNAs should not document tasks they did not perform. This lack of communication and documentation led to the resident not receiving the recommended ambulation program as intended.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide appropriate care for a resident who was incontinent of bowel and bladder, leading to a deficiency in preventing urinary tract infections. The resident, who had diagnoses including Dementia with Agitation and Major Depressive Disorder, required total assistance for toileting and was frequently incontinent. On the morning of the survey, the resident was found wearing a urine-soaked brief and wet linens, indicating a lack of timely incontinence care. The resident reported not receiving morning care and was observed ringing the call bell for assistance, which was delayed. Certified Nursing Assistant #5, responsible for the resident's care, admitted to not providing care all morning and stated the resident had refused care. However, there was no documentation of care refusal, and the CNA did not report the refusal to the Charge Nurse as required by the facility's policy. The CNA acknowledged that they should have reported the refusal and encouraged the resident to accept care. The facility's policy required residents to be checked every two hours, but this was not adhered to in this case. Interviews with the Nurse Manager and the Director of Nursing Services revealed that the CNA failed to follow protocol by not reporting the resident's refusal of care. The facility's policy required CNAs to report refusals to the Charge Nurse and document them in the progress notes, which was not done. The deficiency was attributed to the CNA's failure to provide timely incontinence care and report refusals, leading to the resident being left in a urine-soaked brief for an extended period.
Failure to Adhere to Oxygen Therapy Orders
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as Resident #57, who required oxygen therapy. The resident had a physician's order to receive 4 liters of oxygen per minute via a mist collar to a tracheostomy continuously. However, on multiple occasions, the resident was observed receiving 6 liters of oxygen per minute instead. This discrepancy was noted during observations on several dates, where the oxygen concentrator's display indicated the incorrect setting. The facility's policy required monitoring of oxygen saturation levels and notifying the physician if levels were not within acceptable ranges, but this was not adhered to. Interviews with nursing staff revealed a lack of adherence to the physician's orders and facility policy. Registered Nurse #3 admitted to checking the oxygen level and mistakenly believing it was set correctly, while Registered Nurse Manager #5 confirmed the error and emphasized the responsibility of the nursing staff to monitor and document the resident's oxygen levels. The physician expressed expectations for the nursing staff to follow orders and monitor respiratory levels, highlighting the potential risks of incorrect oxygen therapy. The Director of Nursing Services reiterated the expectation for staff to monitor oxygen levels and settings as per physician orders.
Failure to Ensure Timely Laboratory Services for Resident
Penalty
Summary
The facility failed to ensure timely laboratory services for Resident #41, who was under Transmission-Based Precautions for a Methicillin-Resistant Staphylococcus aureus (MRSA) infection. The resident was receiving Vancomycin, an antibiotic, and a Vancomycin trough level test was ordered by the physician to be conducted on 7/9/2024. However, there was no documented evidence that this laboratory test was completed, which is crucial for monitoring the therapeutic dosage of the medication. The facility's protocol requires nursing staff to process test requisitions and ensure that laboratory results are communicated to the physician. Despite this, the Vancomycin trough level test ordered for 7/9/2024 was not collected, and the nursing staff did not follow up on the status of the order. Interviews with the Registered Nurse Unit Manager and Licensed Practical Nurse revealed that the order was entered into the laboratory system, but the laboratory did not collect the sample. The physician did not follow up on the test due to attending to another health issue of the resident. The Director of Nursing Services acknowledged the failure to collect the Vancomycin trough level and stated that both the nurse on the unit and the resident's physician were responsible for ensuring the completion of laboratory work. The laboratory technician confirmed that they did not see the order for the test on 7/9/2024, indicating a possible issue with the laboratory's processing of the order. This oversight resulted in a delay in monitoring the resident's Vancomycin levels, which is critical for managing the resident's MRSA infection.
Failure to Adhere to Contact Precautions for Resident with Infection
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by an incident involving a resident with a physician's order for Strict Contact Precautions due to Pseudomonas Aeruginosa in the urine. The Licensed Practical Nurse (LPN) responsible for administering medications to this resident entered the room without wearing the required personal protective equipment (PPE), specifically a gown and gloves, despite clear signage indicating the necessity of such precautions. The LPN misunderstood the requirement, believing that PPE was only necessary for high-contact care activities, not for medication administration. The resident involved had a history of urinary tract infection, epilepsy, and schizoaffective disorder, and was dependent on staff for all activities of daily living. The resident's care plan included implementing transmission-based precautions as per the physician's order. The Registered Nurse Infection Preventionist and the Director of Nursing Services both confirmed that the LPN should have adhered to the contact precautions by wearing a gown and gloves, as indicated by the signage outside the resident's room. This oversight highlights a lapse in adherence to the facility's infection control policy, which aims to prevent the spread of infections through proper use of isolation precautions.
Incomplete Documentation of Resident's Medical Assessment
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident reviewed for abuse during a survey. A family member reported observing bruising on the resident's left eye during a virtual meeting. Despite the family member's report to the Director of Nursing Services and the Administrator, there was no documentation of a skin assessment or medical evaluation in the resident's medical record. The facility's policy requires documentation of objective observations and incidents involving residents, but this was not adhered to in this case. The Director of Nursing Services assessed the resident and concluded the discoloration was due to a birthmark or pigmentation, but failed to document the assessment or communication with the family. Similarly, the Physician Assistant evaluated the resident and determined the discoloration was not trauma-related, but did not document their findings, as they considered it a verbal concern. The Administrator acknowledged awareness of the allegation and stated that licensed providers are expected to document all medical assessments, which was not done in this instance.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,100 citations issued within 25 miles in the last 12 months — including the 18 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Great Neck
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Northwell Health Stern Family Center For Rehabilit | 1.3 mi | ★★★★★ | 0 | 0 |
| Highfield Gardens Care Center Of Great Neck | 1.5 mi | ★★★★★ | 0 | 0 |
| Little Neck Care Center | 1.9 mi | ★★★★★ | 1 | 1 |
| Parker Jewish Institute For Health Care & Rehab | 2.6 mi | ★★★★★ | 1 | 0 |
| New Glen Oaks Nursing Home, Inc | 2.9 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for The Grand Rehabilitation And Nursing At Great Neck.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.