Inspection Reports for Rose Garden Nursing And Rehabilitation Center

1579 Old Freehold Road, Toms River, NJ, 08753

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Inspection Report Summary

The most recent inspection on November 20, 2025, did not identify any deficiencies and focused on informing individuals about privacy practices. Earlier inspections showed a mix of results, with the May 8, 2024 re-inspection citing multiple deficiencies related to emergency preparedness, staffing, food safety, infection control, and fire safety measures. Prior reports noted issues with food sanitation, staffing ratios, and fire alarm notification devices, while complaint investigations, including one in March 2022, were unsubstantiated. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility appears to have addressed prior deficiencies, as indicated by the clean findings in the most recent inspection.

Deficiencies (last 4 years)

Deficiencies (over 4 years) 3.3 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

37% better than New Jersey average
New Jersey average: 5.2 deficiencies/year

Deficiencies per year

12 9 6 3 0
2021
2022
2024
2025

Census

Latest occupancy rate 111 residents

Based on a May 2024 inspection.

This facility has shown a steady increase in demand based on occupancy rates.

Occupancy over time

80 88 96 104 112 120 Jan 2021 Apr 2021 Jan 2022 Mar 2022 May 2024

Notice

Deficiencies: 0 Date: Nov 20, 2025

Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their medical information may be used and disclosed, and their rights related to this information.

Findings
The notice details the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and the legal duties of NJDHSS to protect privacy.

Report Facts
Effective date: 2011

Employees mentioned
NameTitleContext
Devon L. GrafDirector, Office of Legal and Regulatory ComplianceListed as NJDHSS Privacy Officer contact for questions about the notice

Inspection Report

Re-Inspection
Census: 111 Deficiencies: 10 Date: May 8, 2024

Visit Reason
The visit was a Life Safety Code Survey and post-certification revisit to verify correction of previously cited deficiencies related to fire safety, maintenance, and emergency preparedness.

Findings
The facility was found not in substantial compliance with emergency preparedness and life safety code requirements, including deficiencies in emergency preparedness plan updates, Medicaid/Medicare coverage notices, professional standards for services, respiratory care, nursing staff sufficiency, food safety, infection control, fire alarm system testing, portable fire extinguisher inspections, fire door maintenance, and emergency generator remote stop button installation. Corrective actions were planned or implemented for all cited deficiencies.

Deficiencies (10)
Failure to annually review and update the Emergency Preparedness Plan (EPP).
Failure to issue required Medicaid/Medicare beneficiary notices to residents.
Failure to meet professional standards for services provided, including failure to follow physician orders for weekly weights.
Failure to provide sufficient nursing staff to meet resident needs.
Failure to maintain food safety and sanitation, including improper food storage and labeling.
Failure to maintain infection prevention and control program, including improper handling of oxygen equipment and masks.
Failure to ensure smoke detection sensitivity testing every alternate year as required by NFPA 72.
Failure to perform monthly visual inspections on all portable fire extinguishers.
Failure of one of five exit access stairwell doors to properly latch, compromising fire-rated construction.
Failure to install a remote manual stop station for the emergency generator as required by NFPA 110.
Report Facts
Census: 111 Fire extinguishers inspected: 21 Fire alarm quarterly inspections reviewed: 10 Deficiency completion dates: 5

Inspection Report

Complaint Investigation
Census: 106 Deficiencies: 0 Date: Mar 15, 2022

Visit Reason
The inspection was conducted in response to a complaint identified as NJ150977.

Complaint Details
Complaint#: NJ150977. The facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, for long term care facilities.

Report Facts
Sample Size: 4

Inspection Report

Annual Inspection
Census: 101 Deficiencies: 3 Date: Jan 3, 2022

Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.

Findings
Deficiencies were cited related to food procurement, storage, preparation, and sanitation practices, failure to maintain required minimum direct care staff-to-shift ratio, and lack of fire alarm notification devices in outdoor resident areas. Corrective actions and plans of correction were provided for each deficiency.

Deficiencies (3)
Facility failed to maintain proper kitchen sanitation practices and properly store dry foods in a safe and sanitary environment to prevent potential food borne illness.
Facility failed to maintain the required minimum direct care staff-to-shift ratio as mandated by the state of New Jersey for 1 of 14 day shifts reviewed.
Facility failed to provide fire alarm notification by audible and visible signals for 2 enclosed outdoor resident areas.
Report Facts
Census: 101 Deficient CNA staffing day shifts: 1 Required CNAs on 11/28/21 day shift: 13 Actual CNAs on 11/28/21 day shift: 9

Employees mentioned
NameTitleContext
Food Service DirectorAcknowledged deficiencies in kitchen sanitation and food storage
Licensed Practical Nurse Unit ManagerReported staffing on 2nd floor during inspection
Staffing CoordinatorAcknowledged awareness of state staffing ratios and use of in-house agency
Maintenance DirectorConfirmed lack of fire alarm notification devices in outdoor resident areas

Inspection Report

Routine
Census: 110 Deficiencies: 0 Date: Apr 20, 2021

Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations related to COVID-19.

Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.

Report Facts
Sample size: 6

Inspection Report

Routine
Census: 92 Deficiencies: 0 Date: Jan 7, 2021

Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.

Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.

Report Facts
Sample size: 8

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