Boulder Park Terrace: Family Never Notified of Falls - MI
The resident, identified in inspection records only as R1, was admitted to the facility on July 25, 2025. She came from an assisted living facility by way of a hospital stay, carrying a diagnosis of a fractured right humerus, along with breast, brain, and bone cancer. Her family had already declined surgical repair of the right arm fracture. She was there, a progress note said, to strengthen her legs. She had been falling.
The admission paperwork, including the form designating who could make medical decisions for her, was not completed until three days after she arrived.
That gap mattered almost immediately.
On the afternoon of July 26, a certified nursing aide found her sitting in her wheelchair. She reached up with her left arm to grab the bed mobility bar to begin a transfer. She heard a pop. She could no longer move the arm. A nurse who came to the room noted the arm was visibly misaligned. EMS was called just after 6 p.m. and arrived within five minutes.
Before she was loaded into the ambulance, staff gave her the bed hold policy and transfer form. What they did not do was call anyone in her family. The progress note recorded that the emergency contact listed in her chart had no phone number attached to it. The Director of Nursing was notified at 6:50 p.m. The on-call provider was reached at 7:02 p.m. Her family was not reached at all.
She returned to the facility that night at 8:15 p.m. with a fractured left humerus and her arm in a sling. She was in pain.
Three days later, on the evening of July 29, she was found on the floor of her room, on her right side, without grip socks, having not used her call light. Her daughter was visiting earlier that same afternoon. By 11:29 p.m., she was telling staff she was in great pain and believed she had broken her right elbow. She was asking to go to the emergency room. An ambulance left with her at 11:35 p.m.
Again, no one called her emergency contact.
The man identified in inspection records as Emergency Contact B spoke with an investigator by phone on August 13, nearly three weeks after the first ambulance call. He said he was never informed of either hospital transfer.
When inspectors interviewed the facility's nursing home administrator on August 14, she confirmed that the admissions policy had not been followed on the day of R1's arrival, and that staff should have collected the emergency contact's phone number before or during admission. The admission form designating who held medical decision-making authority for this woman, a cancer patient who had already fractured one arm before she walked through the door, sat incomplete for her first three days in the facility's care.
The inspection was triggered by a complaint and classified as resulting in minimal harm or potential for actual harm. The citation covers one resident.
What the record shows is a woman who broke her left arm on day two of her stay and her right elbow on day four, who was sent to the hospital twice in the span of 72 hours, and whose family contact sat unreachable in a chart with a blank where his phone number should have been. The administrator confirmed the number should have been there. It wasn't.
Her emergency contact learned what had happened to her from an investigator, weeks later, on the phone.
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.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
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 resident, identified in inspection records only as R1, was admitted to the facility on July 25, 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.