Rose Garden Nursing and Rehabilitation Center
1579 Old Freehold Road, Toms River, NJ 08753 · Ocean County · 128 certified beds · avg 114 residents/day · certified since Dec 1, 1997
Abuse citation flag (CMS)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Oct 31, 2025 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jul 31, 2025 (Past Non-Compliance)
All citations in the current public record (21)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Oct 31, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Sep 18, 2025 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Sep 18, 2025 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Sep 18, 2025 | D · Potential for harm, one-off | The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function. |
| Sep 18, 2025 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Sep 18, 2025 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Sep 18, 2025 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Sep 18, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Sep 18, 2025 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Sep 18, 2025 | D · Potential for harm, one-off | The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience. |
| Sep 18, 2025 | D · Potential for harm, one-off | The facility's quality committee — the internal group responsible for finding and fixing care problems — did not have the required members or did not meet at least every three months. |
| Sep 18, 2025 | D · Potential for harm, one-off | The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective. |
| Sep 18, 2025 | D · Potential for harm, one-off | The facility did not designate a qualified infection preventionist — a trained person responsible for running the infection prevention and control program. |
| Sep 18, 2025 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| May 8, 2024 | F · Potential for harm, facility-wide | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. |
| May 8, 2024 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| May 8, 2024 | D · Potential for harm, one-off | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| May 8, 2024 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| May 8, 2024 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| May 8, 2024 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jan 3, 2022 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (6 → 13).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 1 | 0 | E |
| 2024 | 6 | 0 | F |
| 2025 | 14 | 1 | J ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $17,345.
| Date | Type | Amount / length |
|---|---|---|
| Sep 18, 2025 | Fine | $17,345 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | New Jersey avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.69 | 3.88 | 3.95 | top 48% in New Jersey; bottom 46% in the U.S. |
| Registered Nurse hours | 0.47 | 0.67 | 0.69 | bottom 35% in New Jersey; bottom 33% in the U.S. |
| Weekend total nurse staffing | 3.06 | 3.53 | 3.50 | bottom 28% in New Jersey; bottom 34% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.32 | 0.50 | 0.48 | bottom 36% in New Jersey; bottom 37% in the U.S. |
| Total nursing staff turnover (%) | 41.7 | 39.7 | 45.8 | bottom 44% in New Jersey; top 41% in the U.S. |
| RN turnover (%) | 40.0 | 37.7 | 42.9 | bottom 44% in New Jersey; top 46% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.70, RN 0.47, weekend 3.07. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 5/5 · short-stay residents: 4/5
Who owns this facility
For profit - Individual
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Shawn, Andrew | Individual | Direct Ownership Interest | NOT APPLICABLE | 05/14/2005 |
| Shawn, Andrew | Individual | Corporate Director | NOT APPLICABLE | 06/01/1984 |
| Shawn, Andrew | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/15/2005 |
| Shawn, Andrew | Individual | General Partnership Interest | NOT APPLICABLE | 06/01/1984 |
| Shawn, Andrew | Individual | ADP of the SNF | NOT APPLICABLE | 02/07/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
- "Who completes resident assessments here, and how do you check them for accuracy?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Complete Care at Bey Lea, LLC | 0.9 mi | Toms River, NJ | ★★★★☆ | 4/5 | |
| Hampton Ridge Healthcare and Rehabilitation | 1.3 mi | Toms River, NJ | ★★★★☆ | 3/5 | |
| Childrens Specialized Hospital Toms River | 1.3 mi | Toms River, NJ | ★★★★★ | 4/5 | |
| Complete Care at Green Acres | 1.8 mi | Toms River, NJ | ★★★★★ | 5/5 | |
| Complete Care at Shorrock | 2.8 mi | Brick, NJ | ★★★★★ | 4/5 | |
| Community Medical Center Tcu | 2.8 mi | Toms River, NJ | ★★★★★ | 5/5 | |
| Harrogate Village | 3.1 mi | Lakewood, NJ | ★★★★★ | 4/5 | |
| Complete Care at Holiday City | 3.2 mi | Toms River, NJ | ★★★☆☆ | 3/5 | |
| Shore Gardens Rehabilitation and Nursing Center | 3.3 mi | Toms River, NJ | ★☆☆☆☆ | 1/5 | |
| Complete Care at Arbors | 3.9 mi | Toms River, NJ | ★★★★☆ | 3/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 315421.