Boulder Park Terrace: Pain Left Untreated for Weeks - MI
The resident, identified in inspection records only as Resident 7, was a patient at Boulder Park Terrace when federal inspectors arrived on November 21, 2025, following a complaint. What they found was a month-long failure so basic that the facility's own Director of Nursing struggled to explain it.
A registered nurse told inspectors that Resident 7 had been experiencing pain during wound dressing changes for a full month, and that the pain had grown significantly worse over the last week or two. Nobody had ordered pain assessments. Nobody had documented what the resident was going through. Nobody had called a doctor.
The Director of Nursing, interviewed at 12:45 p.m. on the day of the inspection, did not dispute any of it. Pain assessments should be completed each shift, she told inspectors. There should have been an order in place. She said she was not sure why there wasn't one.
She went further. If Resident 7 was in pain, she said, nursing staff should have at minimum been giving him acetaminophen from the facility's standing orders. If that wasn't working, someone should have contacted the provider. She agreed, when inspectors pressed her, that giving Resident 7 a pain medication before dressing changes, to blunt what was coming, would have been beneficial.
None of that happened. For a month.
The facility's own pain management policy, last revised in March 2015, spells out the obligation in plain terms: complete a pain assessment every shift for any resident with pain, document all findings, notify the provider when pain is uncontrolled, reassess after any intervention, and update the care plan as needed. Nurses are listed as responsible for every one of those steps.
Inspectors rated the violation as causing actual harm, meaning the failure wasn't theoretical. Resident 7 was hurt by it.
The inspection record doesn't describe what kind of wound Resident 7 had, how old he was, or what his broader medical situation looked like. It doesn't say whether he asked for help, or whether he was able to. What it does say is that a registered nurse on staff knew he had been in pain for a month, knew it had gotten worse recently, and that across that entire stretch of time, not one pain assessment was completed and not one call went out to a physician.
Wound dressing changes are already among the more painful routine procedures in a nursing facility. The wound has to be cleaned, old dressings removed, new ones applied. For a resident whose wound was causing enough pain that staff noticed and remembered it, and described it to inspectors in those terms, going through that procedure without any medication, without any documentation, without any medical response, for four weeks, is not a minor oversight.
The Director of Nursing's own words made that clear. She wasn't defending what happened. She was listing, one by one, the things that should have occurred and didn't.
What inspectors did not find, and what the record does not contain, is any explanation for why the gap existed. No staffing shortage cited. No system breakdown identified. No moment where someone tried to get an order and was turned away. The registered nurse knew. The Director of Nursing, by her own account, understood exactly what the standard of care required. The policy was on paper. The standing orders for acetaminophen were available.
Resident 7 went through his dressing changes anyway. Every time, for a month, without relief.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Boulder Park Terrace from 2025-11-21 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.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 26, 2026 · Our methodology
Boulder Park Terrace in Charlevoix, MI was cited for violations during a health inspection on November 21, 2025.
What they found was a month-long failure so basic that the facility's own Director of Nursing struggled to explain it.
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.