Boulder Park Terrace
Open-data reference.
Boulder Park Terrace is a non profit - corporation facility in Charlevoix, MI with 72 certified beds and a 1-star overall CMS rating. The facility has 50 deficiency records on file.
14676 West Upright, Charlevoix, MI 49720
Phone: 2315471005
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 235526
- Ownership
- Non profit - Corporation
- Provider Type
- Medicare and Medicaid
- Beds
- 72
- Residents
- 54
- In Hospital
- No
- County
- Charlevoix
- Last Inspection
- Jun 5, 2025
Staffing Data
- RN Hours
- 0.93 (nat'l avg: 0.68)
- LPN Hours
- 0.44
- CNA Hours
- 1.31
- Total Nursing Hours
- 2.68 (nat'l avg: 3.89)
- PT Hours
- 0.03
What the CMS Record Reveals About Boulder Park Terrace
Boulder Park Terrace operates 72 certified beds in Charlevoix, MI with approximately 54 residents currently in care, and carries a CMS overall rating of 1 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (1★), staffing levels (2★), and quality measures (2★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 50 deficiency records from recent surveys, of which 7 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. No fines or payment denials have been assessed against this provider, suggesting issues — if any — did not rise to the enforcement threshold. Staffing is reported at 2.68 total nursing hours per resident day (national average 3.89), with RN coverage at 0.93 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "Non profit - Corporation" ownership and operating as a "Medicare and Medicaid" provider, Boulder Park Terrace falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (50 most recent)
Provide safe, appropriate pain management for a resident who requires such services.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 19, 2025
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 19, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 19, 2025
Protect each resident from the wrongful use of the resident's belongings or money.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Dec 19, 2025
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Dec 19, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Sep 12, 2025
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Category: Resident Rights Deficiencies
Corrected: Sep 12, 2025
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category: Resident Rights Deficiencies
Corrected: Sep 12, 2025
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Sep 9, 2025
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Category: Pharmacy Service Deficiencies
Corrected: Jul 7, 2025
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Category: Pharmacy Service Deficiencies
Corrected: Jul 7, 2025
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 7, 2025
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Category: Nursing and Physician Services Deficiencies
Corrected: Jul 7, 2025
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jul 7, 2025
Assure that each resident’s assessment is updated at least once every 3 months.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jul 7, 2025
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Category: Resident Rights Deficiencies
Corrected: Jul 7, 2025
Respond appropriately to all alleged violations.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jul 7, 2025
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Sep 3, 2025
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jul 7, 2025
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Sep 3, 2025
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.
Category: Resident Rights Deficiencies
Corrected: Jul 7, 2025
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Category: Resident Rights Deficiencies
Corrected: Jul 7, 2025
Ensure that residents are fully informed and understand their health status, care and treatments.
Category: Resident Rights Deficiencies
Corrected: Jul 7, 2025
Have a plan that describes the process for conducting QAPI and QAA activities.
Category: Administration Deficiencies
Corrected: Jul 7, 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.
Category: Pharmacy Service Deficiencies
Corrected: Jul 7, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jul 7, 2025
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jul 7, 2025
PASARR screening for Mental disorders or Intellectual Disabilities
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jul 7, 2025
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Category: Nutrition and Dietary Deficiencies
Corrected: Mar 29, 2025
Post nurse staffing information every day.
Category: Nursing and Physician Services Deficiencies
Corrected: Dec 13, 2024
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Category: Nursing and Physician Services Deficiencies
Corrected: Dec 13, 2024
Respond appropriately to all alleged violations.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Dec 13, 2024
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Dec 13, 2024
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.
Category: Resident Rights Deficiencies
Corrected: Dec 13, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 9, 2024
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Category: Nursing and Physician Services Deficiencies
Corrected: Jun 11, 2024
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category: Resident Rights Deficiencies
Corrected: Jun 11, 2024
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Category: Administration Deficiencies
Corrected: Jun 11, 2024
Provide or obtain dental services for each resident.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 11, 2024
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Category: Pharmacy Service Deficiencies
Corrected: Jun 11, 2024
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 11, 2024
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jun 11, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jun 11, 2024
Give residents a notice of rights, rules, services and charges.
Category: Resident Rights Deficiencies
Corrected: Jun 11, 2024
Allow residents to self-administer drugs if determined clinically appropriate.
Category: Resident Rights Deficiencies
Corrected: Jun 11, 2024
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 11, 2024
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Category: Nursing and Physician Services Deficiencies
Corrected: Feb 22, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Feb 22, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Jun 15, 2023
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Category: Nutrition and Dietary Deficiencies
Corrected: Jun 15, 2023
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 21.1% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 6.8% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 4.5% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 0.0% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 1.9% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 7.2% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 99.4% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 95.3% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 2.6% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 25.2% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 38.0% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 100.0% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 95.7% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 5.1% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 19.0% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 21.6% | Yes |
Penalty History
| Date | Type | Amount |
|---|---|---|
| Jun 5, 2025 | Payment Denial | - |
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Frequently Asked Questions
What is the overall CMS rating for Boulder Park Terrace?
What are the staffing levels at Boulder Park Terrace?
How many beds does Boulder Park Terrace have?
Does Boulder Park Terrace have any deficiencies on record?
Has Boulder Park Terrace received any fines or penalties?
Who owns Boulder Park Terrace?
When was Boulder Park Terrace last inspected?
What quality measures are tracked for Boulder Park Terrace?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.