Boulder Park Terrace: Fall Prevention Failure - MI
The fall happened on July 29, 2025. The resident, identified in federal inspection records only as R1, had been admitted to the facility on July 25 with a fracture of the right humerus, along with diagnoses of neoplasm of the breast, brain, and bone.
On the day she arrived, staff created a care plan that identified her as at risk for falls and listed one specific approach: ensure she has grippy socks or footwear with grippy soles for safe ambulation and transfers. The plan was created July 25. The fall happened July 29.
When a nurse entered her room at 9:05 p.m. that night, R1 was on her right side on the floor. She had no grippy socks on. She had not activated her call light for assistance.
Nobody had put the socks on her.
More than two hours passed. At 11:29 p.m., a progress note records that R1 was now saying she was in great pain and believed she had broken her right elbow. She was asking to go to the emergency room. The ambulance departed at 11:35 p.m.
The facility's nursing home administrator confirmed during an August 14 interview with inspectors that R1 should have been wearing the proper foot interventions on July 29. That admission is the clearest possible summary of what went wrong: a woman with a fractured arm, already flagged as a fall risk on her first day, went without a basic precaution that staff had themselves committed to providing.
The inspection, a complaint survey completed August 14, 2025, cited Boulder Park Terrace for failing to follow care plan interventions to prevent a fall. Inspectors reviewed three residents for falls and found the failure in R1's case. The citation was tagged at a level of minimal harm or potential for actual harm, a designation that reflects what regulators documented, though R1 left the building in an ambulance.
The facility's own falls protocol states that staff and the physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. R1's care plan was exactly that, a written intervention, created the day she walked in, addressing the exact risk that materialized four days later.
Grip socks are among the simplest fall prevention tools in use in nursing facilities. They cost almost nothing. They require no clinical training to put on a resident. The care plan did not call for a complex intervention or a specialist or a piece of equipment that might be hard to locate on a night shift. It called for socks.
R1 came to Boulder Park Terrace already injured. Her records reflect a woman dealing with a fracture and cancer affecting her breast, brain, and bone. She was not a hypothetical fall risk. She was a person whose fracture was the documented reason for the care plan entry in the first place.
The progress note from 9:05 p.m. is written in the clipped shorthand of clinical documentation: called to resident room, observed resident on her right side on the floor, no grippy socks, did not activate call light. Two hours and twenty-four minutes later, the next note captures what that fall cost her: great pain, a suspected broken elbow, a request for the emergency room.
The ambulance left at 11:35 p.m.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Boulder Park Terrace from 2025-08-14 including all violations, facility responses, and corrective action plans.
Additional Resources
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.
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Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 20, 2026 · Our methodology
Boulder Park Terrace in Charlevoix, MI was cited for violations during a health inspection on August 14, 2025.
The fall happened on July 29, 2025.
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.