D-
44/100Boulder Park Terrace Inspection Report, Violations & Safety Grade (Charlevoix, Michigan)
14676 West Upright, Charlevoix, Michigan 49720
Phone: 2315471005
CMS Overall:1/5
Overview & Bed Count
Certified Beds
72
Avg Residents/Day
47.4
Ownership
Non profit - Corporation
Provider Type
Medicare and Medicaid
County
Charlevoix
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
Yes
CMS Star Ratings
Overall1/5
Health1/5
Staffing1/5
Quality4/5
Nurse Staffing Check
| Metric | This Facility | Michigan Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.00 | 0.78 | -0.78 |
| Total Nurse Hours per Resident per Day | 0.00 | 4.03 | -4.03 |
| CMS Staffing Rating | 1/5 | 3.6/5 | - |
| Nursing Staff Turnover | N/A | 44.6% | - |
Health Citation History
65 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-07-09 | Quality of Life and Care Deficiencies | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | G – Actual Harm |
| 2026-07-09 | Quality of Life and Care Deficiencies | Provide enough food/fluids to maintain a resident's health. | G – Actual Harm |
| 2026-07-09 | Nursing and Physician Services Deficiencies | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | F – Moderate Harm Potential |
| 2026-07-09 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F – Moderate Harm Potential |
| 2026-07-09 | Environmental Deficiencies | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | F – Moderate Harm Potential |
| 2026-07-09 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | E – Moderate Harm Potential |
| 2026-07-09 | Resident Rights Deficiencies | Keep residents' personal and medical records private and confidential. | D – Moderate Harm Potential |
| 2026-07-09 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D – Moderate Harm Potential |
| 2026-07-09 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Respond appropriately to all alleged violations. | D – Moderate Harm Potential |
| 2026-07-09 | Resident Rights Deficiencies | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | D – Moderate Harm Potential |
| 2026-07-09 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D – Moderate Harm Potential |
| 2026-07-09 | Quality of Life and Care Deficiencies | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D – Moderate Harm Potential |
| 2026-07-09 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | D – Moderate Harm Potential |
| 2026-03-25 | Nursing and Physician Services Deficiencies | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | F – Moderate Harm Potential |
| 2026-03-25 | Administration Deficiencies | Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. | F – Moderate Harm Potential |
| 2026-03-25 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | E – Moderate Harm Potential |
| 2026-03-25 | Quality of Life and Care Deficiencies | Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | D – Moderate Harm Potential |
| 2025-11-21 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | G – Actual Harm |
| 2025-11-21 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from the wrongful use of the resident's belongings or money. | G – Actual Harm |
| 2025-11-21 | Quality of Life and Care Deficiencies | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | G – Actual Harm |
| 2025-11-21 | Quality of Life and Care Deficiencies | Provide safe, appropriate pain management for a resident who requires such services. | G – Actual Harm |
| 2025-11-21 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D – Moderate Harm Potential |
| 2025-08-14 | Resident Rights Deficiencies | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D – Moderate Harm Potential |
| 2025-08-14 | Resident Rights Deficiencies | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | D – Moderate Harm Potential |
| 2025-08-14 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D – Moderate Harm Potential |
| 2025-07-17 | Resident Assessment and Care Planning Deficiencies | Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | D – Moderate Harm Potential |
| 2025-06-05 | Administration Deficiencies | Have a plan that describes the process for conducting QAPI and QAA activities. | F – Moderate Harm Potential |
| 2025-06-05 | Resident Rights Deficiencies | Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | E – Moderate Harm Potential |
| 2025-06-05 | Resident Rights Deficiencies | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | E – Moderate Harm Potential |
| 2025-06-05 | Nursing and Physician Services Deficiencies | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | E – Moderate Harm Potential |
| 2025-06-05 | Pharmacy Service Deficiencies | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | E – Moderate Harm Potential |
| 2025-06-05 | Resident Rights Deficiencies | Ensure that residents are fully informed and understand their health status, care and treatments. | D – Moderate Harm Potential |
| 2025-06-05 | Resident Rights Deficiencies | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | D – Moderate Harm Potential |
| 2025-06-05 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D – Moderate Harm Potential |
| 2025-06-05 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. | D – Moderate Harm Potential |
| 2025-06-05 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D – Moderate Harm Potential |
| 2025-06-05 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Respond appropriately to all alleged violations. | D – Moderate Harm Potential |
| 2025-06-05 | Resident Assessment and Care Planning Deficiencies | Assure that each resident’s assessment is updated at least once every 3 months. | D – Moderate Harm Potential |
| 2025-06-05 | Resident Assessment and Care Planning Deficiencies | PASARR screening for Mental disorders or Intellectual Disabilities | D – Moderate Harm Potential |
| 2025-06-05 | Resident Assessment and Care Planning Deficiencies | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | D – Moderate Harm Potential |
| 2025-06-05 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D – Moderate Harm Potential |
| 2025-06-05 | Resident Assessment and Care Planning Deficiencies | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D – Moderate Harm Potential |
| 2025-06-05 | Quality of Life and Care Deficiencies | Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | D – Moderate Harm Potential |
| 2025-06-05 | Pharmacy Service Deficiencies | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | D – Moderate Harm Potential |
| 2025-06-05 | Pharmacy Service Deficiencies | Ensure each resident’s drug regimen must be free from unnecessary drugs. | D – Moderate Harm Potential |
| 2025-03-13 | Nutrition and Dietary Deficiencies | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | D – Moderate Harm Potential |
| 2024-11-13 | Nursing and Physician Services Deficiencies | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | F – Moderate Harm Potential |
| 2024-11-13 | Resident Rights Deficiencies | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | D – Moderate Harm Potential |
| 2024-11-13 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D – Moderate Harm Potential |
| 2024-11-13 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Respond appropriately to all alleged violations. | D – Moderate Harm Potential |
Showing 50 of 65 citations.
Fire Safety Citation History
29 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-07-09 | Emergency Preparedness Deficiencies | Conduct testing and exercise requirements. | F – Moderate Harm Potential |
| 2026-07-09 | Egress Deficiencies | Install emergency lighting that can last at least 1 1/2 hours. | F – Moderate Harm Potential |
| 2026-07-09 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | F – Moderate Harm Potential |
| 2026-07-09 | Smoke Deficiencies | Provide properly protected cooking facilities. | F – Moderate Harm Potential |
| 2026-07-09 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | F – Moderate Harm Potential |
| 2026-07-09 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | F – Moderate Harm Potential |
| 2026-07-09 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | F – Moderate Harm Potential |
| 2026-07-09 | Smoke Deficiencies | Install an approved automatic sprinkler system. | D – Moderate Harm Potential |
| 2026-07-09 | Services Deficiencies | Have properly installed electrical wiring and gas equipment. | D – Moderate Harm Potential |
| 2025-06-05 | Emergency Preparedness Deficiencies | Develop and maintain an Emergency Preparedness Program (EP). | F – Moderate Harm Potential |
| 2025-06-05 | Emergency Preparedness Deficiencies | Address subsistence needs for staff and patients. | F – Moderate Harm Potential |
| 2025-06-05 | Emergency Preparedness Deficiencies | Conduct testing and exercise requirements. | F – Moderate Harm Potential |
| 2025-06-05 | Smoke Deficiencies | Provide properly protected cooking facilities. | F – Moderate Harm Potential |
| 2025-06-05 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | F – Moderate Harm Potential |
| 2025-06-05 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | F – Moderate Harm Potential |
| 2025-06-05 | Miscellaneous Deficiencies | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | F – Moderate Harm Potential |
| 2025-06-05 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | F – Moderate Harm Potential |
| 2025-06-05 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure proper usage of power strips and extension cords. | F – Moderate Harm Potential |
| 2025-06-05 | Egress Deficiencies | Have corridors or aisles that are unobstructed and are at least 8 feet in width. | E – Moderate Harm Potential |
| 2025-06-05 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | E – Moderate Harm Potential |
| 2025-06-05 | Smoke Deficiencies | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | E – Moderate Harm Potential |
| 2025-06-05 | Services Deficiencies | Have properly installed electrical wiring and gas equipment. | E – Moderate Harm Potential |
| 2024-05-15 | Emergency Preparedness Deficiencies | Develop a communication plan. | F – Moderate Harm Potential |
| 2024-05-15 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | F – Moderate Harm Potential |
| 2024-05-15 | Services Deficiencies | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | F – Moderate Harm Potential |
| 2024-05-15 | Egress Deficiencies | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | E – Moderate Harm Potential |
| 2024-05-15 | Egress Deficiencies | Have properly located and lighted "Exit" signs. | E – Moderate Harm Potential |
| 2024-05-15 | Smoke Deficiencies | Install smoke barrier doors that can resist smoke for at least 20 minutes. | E – Moderate Harm Potential |
| 2024-05-15 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure proper usage of power strips and extension cords. | E – Moderate Harm Potential |
Total Penalties & Fines
$0
Total Fine Amount (CMS)
0
Number of Fines
2
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2025-11-21 | Payment Denial | - | 44 days starting 2025-12-24 |
| 2025-06-05 | Payment Denial | - | 7 days starting 2025-09-05 |
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Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the Charlevoix area at no cost.
Find Safe, Vetted Facilities Near Charlevoix
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.