Caring Heart Rehab: Elopement Key Left in Open Box - PA
A nurse aide named Employee E12 retrieved it herself, walking the surveyor over and pulling the key from what the inspection report describes as a grievance form box. "Here I will show you," she said. "It's not supposed to be there, but oh look here it is."
Above the box, someone had taped a handwritten sign: "Please take the key back to the nurse's station."
The sign had not worked.
The nursing home administrator, the director of nursing, and the assistant director of nursing all sat for an interview with inspectors that day. The administrator, identified as Employee E1, explained that the wanderguard system, the electronic mechanism designed to lock doors and elevators when a resident wearing a sensor gets too close, was the primary line of defense. The key lock came later. The assistant director of nursing, Employee E4, was direct about why: staff had become desensitized to the wanderguard alarms. They were going off often enough that people had stopped responding to them the way they were supposed to.
So the facility added a physical key. Then the key ended up in a box on the wall.
When the surveyor first approached the nurses station to ask how to access the elevator, the nursing staff member sitting at the desk didn't produce a key or call for one. She gestured toward the elevator. "It's probably in that black box over there," she said.
The inspection, a complaint survey, also documented a separate problem on the third floor, found during the same morning. At 10:00 a.m., a surveyor observed a resident identified as R5 lying in bed receiving a breathing treatment. On the bedside table sat a clear medication cup holding six to eight pills. The pills had been poured and left there. The licensed nurse responsible, Employee E8, confirmed she had prepared the medications but that R5 had asked to complete the breathing treatment first. Employee E8 also confirmed that R5 does not self-administer medication.
The pills sat unattended at the bedside of a resident who could not manage them independently.
The elopement key finding carries the heavier weight. The facility's own policy, revised as recently as November 2024, commits the nursing home to a systematic approach to monitoring residents at risk for wandering, including evaluating hazards, implementing interventions, and monitoring whether those interventions are actually working. The policy also states that staff must respond to door alarms in a timely manner.
The keyed elevator lock was an acknowledgment that the alarm response had broken down. Employees had tuned out the alerts. The key was meant to compensate for that failure. But the key was stored in a way that made it accessible to anyone who walked up to the wall and looked, which is precisely what the surveyor did, with a nurse aide's help, at 10:33 in the morning.
There was no indication in the inspection report that any resident had successfully used the key or reached an elevator unsupervised. The violation was cited at a level of minimal harm or potential for actual harm, affecting few residents. But the logic of the situation is not difficult to follow. A resident who wears a wanderguard and understands that a key opens the elevator, or who simply sees someone else use one, now has a path that the facility's own staff acknowledged the alarms alone could not reliably block.
The sign above the box asked people to return the key to the nurses station. Someone kept not doing that.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Caring Heart Rehabilitation and Nursing Center from 2025-11-25 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
CARING HEART REHABILITATION AND NURSING CENTER in PHILADELPHIA, PA was cited for violations during a health inspection on November 25, 2025.
"Here I will show you," she said.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.