Boulder Park Terrace: Bowel Care Failures Documented - MI
The November 21 complaint inspection, conducted by federal surveyors at the 14676 West Upright facility, found that nurses had failed to follow or document a bowel protocol for at least two residents, identified in inspection records as R3 and R7. The deficiency was cited at a level of minimal harm or potential for actual harm.
R7's records told a stark story. Inspectors reviewed progress notes and electronic medication administration records spanning October 23 through November 21, a stretch of nearly four weeks. Across that entire period, they found no documentation of bowel interventions and no gastrointestinal assessments. Nothing.
The facility's bowel protocol, as described by the Director of Nursing, required nurses to step in when a resident went without a bowel movement for two to six days. The interventions were specific: prune juice and 17 grams of polyethylene glycol, or 10 milligrams of bisacodyl tablets, depending on how many days had passed. The protocol existed. Nurses simply weren't following it, or at minimum, weren't writing down that they had.
On the morning of the inspection, surveyors sat down with the Director of Nursing and walked through what they had found. She was asked what her expectations were for nursing staff when it came to the bowel protocol.
"Well if a resident does not have a bowel movement on days 2 through 6 then they should be following the bowel protocol depending on which day the resident is on for not having a bowel movement," she said.
Asked whether nurses were documenting their interventions as required, she said they should be recording entries either in the medication administration record or in the progress notes.
Then came the confirmation. The Director of Nursing agreed that both R3 and R7 lacked documentation showing nurses had followed the protocol. She agreed that an intervention not documented was considered not done.
Surveyors then asked for the facility's bowel management policy.
"The facility does not have a policy on bowel management," she said. "Nursing is to follow bowel protocol."
The distinction she was drawing, between a policy and a protocol, did nothing to explain the missing records. A protocol without a governing policy is, in practice, a set of instructions with no accountability structure behind it. At Boulder Park Terrace, that gap appears to have mattered. Nurses were expected to know what to do and when. For R3 and R7, the records suggest they either didn't act or didn't record that they had. By the Director of Nursing's own standard, those two outcomes are the same.
Constipation in nursing home residents is not a minor inconvenience. Older adults, particularly those with limited mobility or on medications that slow the gut, face real risks when bowel function goes unmanaged: pain, distension, confusion, and in serious cases, bowel obstruction. Protocols like the one Boulder Park Terrace maintained exist precisely because the consequences of inaction accumulate quietly, day by day, until they don't.
The inspection covered a complaint and was completed November 21, 2025. The deficiency was classified under F0684, which addresses the provision of care and services consistent with professional standards. The level of harm was rated minimal or potential, meaning inspectors did not find evidence that residents had yet suffered serious injury, but the conditions created real risk.
What the records from those four weeks do not show is anyone checking on R7's bowel status, adjusting their care, or noting that the protocol had been considered and acted upon. Four weeks of silence in a chart that was supposed to speak for the care being given.
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: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Boulder Park Terrace in Charlevoix, MI was cited for violations during a health inspection on November 21, 2025.
The deficiency was cited at a level of minimal harm or potential for actual harm.
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.