Boulder Park Terrace

F 0580 Level of Harm - Minimal harm or potential for actual harm

admission.An interview was conducted with the Nursing Home Administrator (NHA) on 8/14/25 at approximately 2:00 p.m. who confirmed that the admissions policy was not being followed on the day of Resident R1's admission into the facility and that staff should have gathered pertinent information such as Emergency Contact B's phone number prior to or on admission.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/14/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Boulder Park Terrace

14676 West Upright Charlevoix, MI 49720

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility failed to form a recapitulation of stay for one Resident (Resident R2) of three residents reviewed for discharge. Findings include:This intake pertains to 2563536Resident R2Review of Resident R2's Electronic Medical Record (EMR) revealed admission to the facility on 7/8/25 and discharge from the facility on 7/10/25 with diagnoses including restlessness and agitation, adult failure to thrive, and anorexia.Review of Resident R2's Progress Notes revealed the following information: 07/10/2025 11:51AM Call to wife.She was not picking up her phone last night and staff unable to leave VMs to her. She was very surprised on all that was replayed to her this am of the occurrences from last night. Informed her that he was taken by the police in handcuffs to the ER because he not only assaulted staff but assaulted a police officer. Relayed that he does not get along in a group setting, that he would not be able to continue staying here. We need to be able to actually care for him and he is refusing meds, refusing care, dumping his urinal, shouting the F word, assaulting staff. She said we could bring him back to her house if we could transport him ourselves. We talked twice this am to communicate the plan. Transporter taking back home now. We are unable to locate his glasses, but will check with the ER next door if he left them over there and attempt to get them back to her. He left with all other belongings, his W/C and rolled walker.There was no recapitulation of stay for Resident R2 located in the EMR.An interview was conducted with the Nursing Home Administrator (NHA) on 8/14/25 at approximately 2:00 p.m. The NHA confirmed that a recapitulation of stay was not completed for Resident R2 prior to discharge on [DATE REDACTED].Review of the facility's Discharge Summary and Plan policy read, in part, When the facility anticipates a resident's discharge to a private residence, another nursing care facility (i.e., skilled, intermediate care, ICF/IID, etc.) a discharge summary and post-discharge plan will be developed which will assist the resident o adjust to his or her new living environment.the discharge summary will include a recapitulation of the resident's stay at this facility and a final summary of

the resident's status at the time of the discharge

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/14/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Boulder Park Terrace

14676 West Upright Charlevoix, MI 49720

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Based on interview and record review the facility failed to follow care plan interventions to prevent a fall for one Resident (Resident R1) of three residents reviewed for falls. Findings include:This intake pertains to 2586236, 2583430Resident R1Review of Resident R1's Electronic Medical Record (EMR) revealed admission to the facility on 7/25/25 with diagnosis including fracture of right humerus and neoplasm of the breast, brain and bone.Review of Resident R1's Progress Notes revealed the following entries: 07/29/2025 9:05PM Called to resident room. Upon entering, observed resident on her R (right) side on the floor, no grippy socks and did not activate call light for assistance 07/29/2025 11:29PM Resident now states she is in great pain & thinks she broke her R elbow and is requesting to go to the ER.Ambulance departed with resident at 11:35 PM. resident was given bed hold policy and transfer form.Review of Resident R1's Care Plans revealed the following: Problem Start Date: 7/25/25; At risk for falls related to R (right) humorous fracture.Approach:.Ensure resident has grippy socks or footwear with grippy soles for safe ambulation and transfers; created 7/25/25.An interview was conducted with the Nursing Home Administrator (NHA) on 8/14/25 at approximately 2:00 p.m. The NHA confirmed that Resident R1 should have been wearing the proper foot interventions on 7/29/29.Review of the facility's Falls-Clinical Protocol policy read, in part, .Based on the proceeding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinical significant consequences of falling.

Event ID:

Facility ID:

If continuation sheet