Boulder Park Terrace
14676 West Upright · Charlevoix, MI · 49720 · 2315471005
72 certified beds Non profit - Corporation
Why this verdict
- Carries CMS’s abuse warning icon.
- Inspection record is far worse than the national median (deficiency count and severity).
- Inspection results are getting worse cycle over cycle, not better.
- 7 citations involved actual harm to residents.
- Staffing hours comfortably above national benchmarks.
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Red flags
CMS abuse warning
CMS flags this facility with its abuse icon: cited for abuse that caused harm in the past year, or potential harm in the past two years.
2 abuse-related citations at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
4 actual-harm citations in the most recent cycle
Inspectors found deficiencies that caused real harm to residents, beyond potential-harm paperwork findings.
Medicare/Medicaid payments were denied
CMS refused payment for new admissions for a period — one of its strongest enforcement tools.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 3 of 5 Quality measures: 2 of 5
| Total nurse hours / resident-day | 3.62 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 1.80 | 0.55–0.75 |
| Weekend hours / resident-day | 3.29 | ≈ weekday level |
| Nursing turnover / year | — | median 45% |
| Fines (3-yr window) | none |
Inspection citations (58 in the current record)
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Potential for harm · E March 25, 2026 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected May 1, 2026 · Quality of Life and Care
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Potential for harm · D March 25, 2026 · found via complaint
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected May 1, 2026 · Quality of Life and Care
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Potential for harm · F March 25, 2026 · found via complaint
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected May 1, 2026 · Nursing and Physician Services
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Potential for harm · F March 25, 2026 · found via complaint
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.
Corrected May 1, 2026 · Administration
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Actual harm · G November 21, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected February 6, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Actual harm · G November 21, 2025 · found via complaint
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected February 6, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Actual harm · G November 21, 2025 · found via complaint
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected December 19, 2025 · Quality of Life and Care
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Actual harm · G November 21, 2025 · found via complaint
Provide safe, appropriate pain management for a resident who requires such services.
Corrected December 19, 2025 · Quality of Life and Care
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Potential for harm · D November 21, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected December 19, 2025 · Quality of Life and Care
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Potential for harm · D August 14, 2025 · found via complaint
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected September 12, 2025 · Resident Rights
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Potential for harm · D August 14, 2025 · found via complaint
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected September 12, 2025 · Resident Rights
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Potential for harm · D August 14, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected September 12, 2025 · Quality of Life and Care
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Potential for harm · D July 17, 2025 · found via complaint
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Corrected September 9, 2025 · Resident Assessment and Care Planning
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Potential for harm · D June 5, 2025
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected July 7, 2025 · Resident Assessment and Care Planning
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Potential for harm · D June 5, 2025
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected July 7, 2025 · Resident Assessment and Care Planning
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Potential for harm · D June 5, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected July 7, 2025 · Resident Assessment and Care Planning
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Potential for harm · E June 5, 2025
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.
Corrected July 7, 2025 · Pharmacy Service
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Potential for harm · F June 5, 2025
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected July 7, 2025 · Administration
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Potential for harm · D June 5, 2025 · found via complaint
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected July 7, 2025 · Resident Rights
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Potential for harm · E June 5, 2025 · found via complaint
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected July 7, 2025 · Resident Rights
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Potential for harm · D June 5, 2025 · found via complaint
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.
Corrected July 7, 2025 · Resident Rights
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Potential for harm · D June 5, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected September 3, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D June 5, 2025 · found via complaint
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected July 7, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D June 5, 2025 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected September 3, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D June 5, 2025 · found via complaint
Respond appropriately to all alleged violations.
Corrected July 7, 2025 · Freedom from Abuse, Neglect, and Exploitation
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| November 21, 2025 | Payment Denial | 44 days |
| June 5, 2025 | Payment Denial | 7 days |
Better-scoring options nearby
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 235526 · certified since August 14, 1992. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.