Boulder Park Terrace: Pressure Ulcer Sends Resident to ER - MI
The November 2025 complaint inspection found the facility had caused actual harm to at least one resident. The inspection report, completed November 21, 2025, cited the facility under F0686, which covers the prevention and treatment of pressure ulcers.
The clinical picture documented in the inspection report was not ambiguous. A nursing note from November 20 at 4:21 p.m. recorded that the facility had received an update from the local ER: the resident had been admitted due to a decubitus ulcer on his buttock, surgery was seeing him the next day, and the likely course of treatment would include a wound vacuum and intravenous antibiotic therapy. His white blood cell count had climbed to 16.8, a marker of active infection. He also presented with hyperglycemia and hyponatremia, a dangerous drop in blood sodium.
The wound itself had been covered with an abdominal pad.
Boulder Park Terrace had a pressure ulcer policy in place. The Clinical Protocol on Pressure Ulcer and Skin Breakdown, dated June 2023, directed nursing staff to fully assess and document pressure sores, including location, stage, length, width, and depth, along with the presence of any drainage or dead tissue. It required pain assessment, documentation of the resident's mobility status, and a record of current treatments including support surfaces. It required staff and practitioners to identify and document significant risk factors, including immobility, recent weight loss, and any history of pressure ulcers.
The gap between what the policy required and what happened to this resident was what brought inspectors to the facility.
A pressure ulcer that advances far enough to require surgical evaluation and IV antibiotics does not develop overnight. Decubitus ulcers, also called bedsores, form when sustained pressure cuts off circulation to skin and underlying tissue, typically over bony areas like the tailbone, hips, and heels. In a resident who cannot reposition himself, consistent monitoring and intervention are the only things standing between early-stage redness and the kind of wound that lands someone in an operating room.
An elevated white blood cell count alongside wound infection, metabolic disruption, and the need for intravenous antibiotics describes a body under significant stress. The resident had been living at the facility. The wound had been covered with an abdominal pad. At some point between the wound's formation and the ambulance call, the clinical escalation the policy was designed to prevent had already occurred.
The inspection was triggered by a complaint. Inspectors classified the level of harm as actual harm, meaning the deficiency had already resulted in real injury to a resident, not a theoretical risk.
Boulder Park Terrace is located at 14676 West Upright Street in Charlevoix, a small city in northern Michigan on the shore of Lake Charlevoix. The facility's provider identification number is 235526.
The inspection report does not describe what the resident's wound looked like when he was still at the facility, how long it had been present, or what documentation, if any, existed before the ER admission note. It does not say whether staff had been assessing the wound, whether a care plan addressed it, or whether anyone had flagged his deteriorating condition before he was transported.
What the record shows is a nursing note written after he was already gone, and a surgical team waiting to see him in the morning.
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.
The November 2025 complaint inspection found the facility had caused actual harm to at least one resident.
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.