Inspection Reports for
Rose Garden Nursing And Rehabilitation Center
1579 Old Freehold Road, Toms River, NJ, 08753
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Notice — Nov 20, 2025
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
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report — May 8, 2024
Re-Inspection
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
Fire extinguishers inspected: 21
Fire alarm quarterly inspections reviewed: 10
Deficiency completion dates: 5
Inspection Report — Mar 15, 2022
Complaint Investigation
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 — Jan 3, 2022
Annual Inspection
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
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
| Name | Title | Context |
|---|---|---|
| Food Service Director | Acknowledged deficiencies in kitchen sanitation and food storage | |
| Licensed Practical Nurse Unit Manager | Reported staffing on 2nd floor during inspection | |
| Staffing Coordinator | Acknowledged awareness of state staffing ratios and use of in-house agency | |
| Maintenance Director | Confirmed lack of fire alarm notification devices in outdoor resident areas |
Inspection Report — Apr 20, 2021
Routine
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 — Jan 7, 2021
Routine
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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