Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rose Garden Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple medical conditions was left unsupervised on an outdoor patio for nearly three hours in hot weather after being taken outside by a CNA who failed to notify other staff. The resident was not checked on by the assigned CNA or any other staff, and was later found by a visitor in distress with signs of heatstroke, dehydration, and second-degree burns, requiring hospital admission.
The facility failed to maintain sufficient nursing staff to meet resident needs, particularly on weekends and night shifts. Residents reported missed care, and staffing records confirmed consistent CNA shortages. Staff interviews highlighted frequent call-outs and unmet staffing plans, contributing to inadequate care.
The facility failed to handle potentially hazardous food safely, as observed by a surveyor. Expired syrup bottles and improperly stored frozen hash browns and French fries were found in the kitchen. The facility's policy requires proper labeling and dating of food items, which was not followed, leading to the removal of these items by the Food Service Director.
The facility failed to issue the required beneficiary notices for two residents, using admission agreements instead of the CMS-10055 form. The AIT admitted awareness of the correct form but stated the facility was waiting for instructions to change their practice, despite the issue being questioned annually during surveys.
A facility failed to follow a physician's order for weekly weights for a resident with surgical aftercare needs and major depressive disorder. The MAR lacked documentation for specific dates, indicating non-compliance. Interviews with staff revealed inconsistencies in the process of obtaining and documenting weights, with the DON citing staffing challenges as a factor. Facility policies emphasized the need for proper documentation and execution of orders, which was not adhered to in this instance.
A resident with chronic respiratory conditions and a PRN oxygen order was not consistently monitored for SPO2 levels, as required by the facility's policy. Despite having an order to administer oxygen if SPO2 fell below 92%, there were no documented SPO2 readings from June 2023 until April 2024, except for a few entries. The facility's DON confirmed the lack of monitoring and acknowledged the need for regular SPO2 checks as per the physician's order.
A facility failed to follow infection control protocols for respiratory equipment for two residents. One resident's nasal cannula tubing was not changed weekly as required, and another resident's nasal cannula was found in a trash can, with a nebulizer mask left exposed. Staff interviews confirmed these lapses, despite the facility's policy to change and cover equipment regularly.
Resident Left Unattended Outdoors Resulting in Heatstroke and Burns
Penalty
Summary
A cognitively impaired, aphasic resident with multiple serious medical conditions, including Alzheimer's disease, brain and colon cancer, and a history of traumatic brain injury, was left unattended on an outdoor patio for approximately two hours and forty minutes during a period of heat and sun exposure. The resident required maximal staff assistance for mobility and activities of daily living and was unable to communicate effectively. After being transported to the patio in a wheelchair by a CNA following lunch, the resident was not monitored or checked on by any staff, and the CNA failed to inform other staff members of the resident's location. During this period, the assigned CNA did not check on the resident or account for their whereabouts, and no other staff intervened. The resident was eventually discovered by another resident and a visitor, slumped over in the wheelchair, with hot, dry skin and an elevated temperature. Emergency services were called, and the resident was transferred to the hospital, where they were diagnosed with heatstroke, dehydration, acute kidney injury, elevated troponin, and second-degree burns (sunburns with blisters) on multiple body areas. Hospital records documented the resident's acute distress, altered mental status, and multiple metabolic complications resulting from the prolonged heat exposure and lack of monitoring. Facility records and staff interviews confirmed that there was no policy in place at the time regarding resident supervision outdoors, and staff failed to follow basic protocols for communication and resident safety. The assigned CNA was unaware of the resident's location for an extended period, did not perform required rounds, and failed to provide necessary care such as hydration, toileting, and skin protection. The lack of monitoring and communication directly resulted in the resident's serious medical deterioration and hospital admission.
Removal Plan
- Checks were implemented on all outdoor areas (patio, courtyard, entrance), checks recorded on log sheets
- Notifications to NJDOH, Ombudsman Office and facility administrative staff were sent
- Patio keypad was changed to locked
- All employees at the facility were educated on Resident Safety/Heat Advisory
- CNA #1 received inservice/education on Resident Safety
- CNA #2 received inservice/education on Resident Safety, knowing your assigned resident's whereabouts, making rounds on assigned residents and received a suspension
- A facility wide inservice on the new Outdoor Resident Policy was initiated with Resident Safety/Updated Log Sheets
- Camera installation on the patio was completed
- Checks remain on all outdoor areas recorded on log sheets
Staffing Deficiencies Impact Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff on a 24-hour basis to meet the needs of residents, as evidenced by multiple observations and interviews. During an initial tour, residents reported a shortage of nurses and aides, particularly on weekends, which affected their care. For instance, one resident mentioned not receiving a bed bath due to staffing shortages. The Resident Council Meeting further highlighted concerns about inadequate staffing, especially at night, with residents noting that staff breaks seemed to coincide, leaving them without necessary care. The facility's staffing records from two separate periods revealed consistent deficiencies in CNA staffing during day shifts and occasional shortages during evening and overnight shifts. For example, during a two-week period in July and August 2023, the facility was deficient in CNA staffing for all 14 day shifts, with similar issues noted in April 2024. Interviews with staff, including a Registered Nurse and a CNA, confirmed these challenges, citing frequent call-outs and insufficient staffing levels, particularly on weekends. The facility's staffing plan, as outlined in the Facility Assessment, was not being met, as confirmed by the Director of Nursing. The plan detailed specific staffing levels for different shifts and floors, but the DON acknowledged that these levels were not consistently achieved, especially on weekends when Unit Managers were not present. This discrepancy between the staffing plan and actual staffing levels contributed to the deficiency in providing adequate care to residents.
Deficient Food Handling and Sanitation Practices
Penalty
Summary
The facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner, as observed by a surveyor in the presence of the Food Service Director (FSD). In the dry storage room, seven bottles of Smucker's Breakfast syrup were found, six of which had expired. The FSD removed these expired syrups from storage. Additionally, in the walk-in freezer, a plastic bag containing frozen hash brown potatoes was covered in ice and lacked any dates, leading to its disposal by the FSD. Furthermore, a box of frozen French fries was found with the bag opened and exposed to air, which was also discarded by the FSD. The facility's policy on Dating and Labeling, established in December 2022, requires all food items stored outside their original containers to be labeled and dated with an expiration date of five days unless otherwise specified. The policy mandates that all kitchen staff are responsible for labeling items as they are opened and stored, with verification by prep cooks and cooks at the end of each service day. The observed deficiencies indicate a failure to adhere to this policy, as evidenced by the presence of expired and improperly stored food items.
Failure to Issue Required Beneficiary Notices
Penalty
Summary
The facility failed to issue the required beneficiary notices for two residents reviewed for Beneficiary Protection Notification. For both residents, the Skilled Nursing Facility Beneficiary Protection Notification Review indicated that their last covered Medicare day was 02/29/2024, and they remained in the facility. The facility claimed to have provided a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage Form CMS-10055 to both residents. However, when the surveyor requested copies of these forms, the Administrator in Training (AIT) provided copies of the residents' signed Admission Agreements instead. During interviews with the surveyor, the AIT admitted that the facility uses section 5 of the admission agreement as the SNFABN instead of the CMS-10055 form. The AIT acknowledged awareness of the CMS-10055 form but stated that the facility was waiting to see if they would be instructed to change their practice. The AIT further clarified that although this issue is questioned every year during surveys, it has never been formally identified as a deficiency until now.
Failure to Document Weekly Weights as Ordered
Penalty
Summary
The facility failed to adhere to a physician's order for weekly weights for a resident, leading to a deficiency in meeting professional standards of quality. The resident, who was admitted with diagnoses including surgical aftercare following digestive system surgery and major depressive disorder, had a physician order for weekly weights to be taken on Mondays before breakfast. However, a review of the Medication Administration Records (MAR) for March and April 2024 revealed that the weights for March 25 and April 15 were not documented, indicating that the weights were not completed as ordered. Interviews with facility staff, including an LPN, the Unit Manager, and the Director of Nursing, revealed inconsistencies in the process of obtaining and documenting weights. The LPN stated that weights are usually done by CNAs, while the Unit Manager confirmed that the MAR was blank for the specified dates and acknowledged that if there is no documentation, the weight was not done. The Director of Nursing noted that due to staffing challenges, nurses are responsible for weighing residents and ensuring documentation in the MAR. The facility's policy on weight monitoring and physician's orders emphasized the need for documentation and execution of orders, which was not followed in this case.
Failure to Monitor SPO2 for Resident with PRN Oxygen Order
Penalty
Summary
The facility failed to consistently assess or measure blood oxygen saturation (SPO2) for a resident with an order for PRN supplemental oxygen use. This deficiency was identified during a survey when an oxygen concentrator was observed in the resident's room but was not in use. The resident, who had diagnoses including chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, and congestive heart failure, had a physician's order to administer oxygen if SPO2 dropped below 92%. However, there was no evidence of regular SPO2 monitoring in the resident's medical records for March and April 2024. The surveyor's review of the electronic medical record revealed that the resident had an active order from June 2023 for PRN oxygen administration if SPO2 fell below 92%. Despite this, there were no documented SPO2 readings from June 2023 until April 2024, except for a few entries in early June 2023 and late April 2024. The facility's Director of Nursing (DON) confirmed the absence of SPO2 monitoring records for the specified period and acknowledged that the physician's order required regular SPO2 checks to determine the need for oxygen therapy. Interviews with facility staff, including the Unit Manager/Registered Nurse, indicated a lack of clarity regarding the facility's policy for PRN oxygen use and SPO2 monitoring. The facility's policy required daily SPO2 checks for residents on PRN oxygen, but this was not adhered to for the resident in question. The DON admitted that the policy had been revised after COVID-19, but the requirement for daily SPO2 checks remained unchanged. This oversight led to the deficiency in providing appropriate respiratory care for the resident.
Infection Control Deficiencies in Respiratory Equipment Management
Penalty
Summary
The facility failed to adhere to infection prevention and control protocols concerning respiratory equipment for two residents. For one resident, the nasal cannula tubing was observed with a date indicating it had not been changed for over two weeks, despite physician orders requiring weekly changes. Interviews with nursing staff confirmed that the tubing should be changed weekly, but it was not done, leading to a lapse in infection control practices. Another resident was found with a nasal cannula draped over a trash can while receiving oxygen therapy, and a nebulizer mask was left exposed on a bedside table. The facility's policy mandates that respiratory equipment should not touch the floor and should be covered when not in use. Interviews with nursing staff revealed that the resident often played with their equipment, but the staff acknowledged that the equipment should not have been left in such conditions. Both residents had significant respiratory diagnoses, including chronic obstructive pulmonary disease and pneumonia, which necessitated careful management of their respiratory equipment. The facility's failure to follow its own policies and physician orders for changing and storing respiratory equipment contributed to the deficiencies observed by the surveyors.
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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.
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Nursing homes near Toms River
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Complete Care At Bey Lea, Llc | 0.9 mi | — | 11 | 0 |
| Hampton Ridge Healthcare And Rehabilitation | 1.3 mi | — | 9 | 0 |
| Childrens Specialized Hospital Toms River | 1.3 mi | — | 0 | 0 |
| Complete Care At Green Acres | 1.8 mi | — | 0 | 0 |
| Complete Care At Shorrock | 2.8 mi | — | 9 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.