ManorCare Boynton Beach: Resident Falls from Window FL
BOYNTON BEACH, FL - A severely cognitively impaired resident at Isles of Boynton Nursing and Rehab Center fell approximately 20 feet from a second-floor window on Christmas Day after staff failed to provide adequate supervision, resulting in serious head and spinal injuries that required emergency hospitalization.
Critical Supervision Failure Led to Preventable Accident
The incident occurred on December 25, 2024, between 7:15 and 7:20 AM when Resident #1 removed the right window panel from his room's window frame and fell to the ground in a narrow area between the building and a palm tree. The 20-foot fall caused multiple serious injuries including a new acute left subdural hemorrhage, intraventricular bleeding, and a compression fracture of the third lumbar vertebra.
State inspectors found that the facility's staff had failed to recognize and respond appropriately to clear exit-seeking behaviors exhibited by the resident throughout the night shift. Despite the resident having a documented history of attempting to leave the building and being placed on one-to-one observation just five days earlier, nursing staff did not implement proper supervision protocols when warning signs emerged.
Licensed Practical Nurse Staff A, who was working the overnight shift, told investigators that she observed the resident at an exit door where the alarm was ringing at approximately 6:15 AM - a clear indication of exit-seeking behavior. However, she only redirected the resident back to his room without implementing the facility's protocol for one-to-one observation. Staff A later acknowledged that "had she known Resident #1 had been exit-seeking prior to his being moved upstairs she would have placed him on 1:1 observation."
The medical consequences of this supervision failure were severe. Hospital records revealed the resident sustained a new small acute left subdural hemorrhage measuring up to 4 millimeters, along with bleeding in the brain's ventricular system. These types of brain injuries can cause increased intracranial pressure, altered mental status, and potential long-term neurological deficits. The compression fracture to his lumbar vertebra required treatment with a back brace and could result in chronic pain and mobility limitations.
Pattern of Unrecognized Exit-Seeking Behaviors
The inspection revealed a troubling pattern of staff failing to recognize and document exit-seeking behaviors throughout the night. Certified Nursing Assistant Staff C reported observing the resident wandering in hallways multiple times between 4:00 AM and 7:16 AM, but these observations were not properly documented or escalated.
Most concerning was that Staff A encountered two clear instances of exit-seeking behavior but failed to classify them as such. Beyond finding the resident at the exit door with the alarm sounding, she also reported that the resident followed her to a supply room and asked about the exit. In both cases, the resident was simply redirected to his room without additional safety measures.
Exit-seeking behavior in nursing home residents with cognitive impairment represents a significant safety risk that requires immediate intervention. These behaviors can escalate quickly and may indicate confusion, agitation, or an attempt to return to familiar environments. Standard nursing home protocols typically require one-to-one supervision for residents displaying such behaviors to prevent serious injuries from falls, wandering into unsafe areas, or in this case, attempting to exit through windows.
The facility's own care plan for the resident, created just two days before the incident, documented his severe cognitive impairment and inability to respond appropriately to questions. His Minimum Data Set assessment indicated he had wandering behaviors and was cognitively impaired to the point where he could not complete basic mental status evaluations.
Communication Breakdown During Shift Changes
A critical communication failure occurred during the shift change that may have contributed to the incident. Staff A stated that while she was informed the resident was "alert with confusion" and had been wandering between rooms during the previous shift, she was not told about his documented history of exit-seeking behaviors from December 20, 2024.
This communication gap violated fundamental nursing standards that require comprehensive handoff information about residents' behavioral risks and safety needs. In facilities caring for cognitively impaired residents, shift reports must include detailed information about recent behavioral changes, risk factors, and any special monitoring requirements.
The facility had previously recognized the resident's exit-seeking risk - he had been placed on one-to-one observation on December 20, 2024, after being observed trying to exit the building. However, when he was moved to the supposedly secure second floor that same day, the intensive supervision was discontinued based on the assumption that the secured unit would prevent exit attempts.
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
ISLES OF BOYNTON NURSING AND REHAB CENTER in BOYNTON BEACH, FL was cited for violations during a health inspection on January 8, 2025.
However, she only redirected the resident back to his room without implementing the facility's protocol for one-to-one observation.
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.