Boulder Park Terrace

F 0600

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Level of Harm - Actual harm Residents Affected - Few

Based on interview and record review, the facility failed to protect the right to be free from verbal abuse by staff for one Resident (#6) of three residents reviewed for abuse. Findings include: This citation pertains to intake: 2667693Resident #6 (Resident R6)Review of the Electronic Medical Record (EMR) for Resident R6 revealed admission to the facility on 9/1/25 with diagnosis of cerebral infarction. Resident R6 scored an 8/15 on a Brief Interview for Mental Status (BIMS) score dated 9/5/25, indicating moderate cognitive impairment. However, the medical

record indicated Resident R6 was responsible for their own medical and financial decisions.An interview was conducted with Social Services Director (SSD) M on 11/20/25 at 1:30 p.m. SSD M stated she was walking down the B hall when Registered Nurse (RN) G stated, Do I prevent a fall or let someone get the [explicit word] beat out of them. SSD M then proceeded down the hallway to grab RN B to assist. SSD M stated she started to hear loud and aggressive shouting and when coming through the doors in the B hall, witnessed RN G in close proximity of Resident R6 stating Because your CNA (Certified Nurse Aide) was busy getting the [explicit word] beat out of her. SSD M stated RN B attempted to diffuse the situation between RN G and Resident R6, but indicated RN G continued to be aggressive in the hallway. SSD M stated they separated RN G and Resident R6 and proceeded to call the Nursing Home Administrator (NHA).An interview was conducted with RN B on 11/20/25 at 1:46 p.m. RN B stated she was assisting a resident with behaviors approximately four rooms down from the incident with Resident R6 and RN G. RN B stated she heard loud voices coming from the hallway and when stepping out to see what was happening, saw RN G inches from the face of Resident R6 and was yelling It's because your CNA was busy getting the [explicit word] beat out of her, that's why! RN B stated RN G's voice was aggressive and angry. RN B stated she went toward Resident R6 to comfort her and Resident R6 stated, I have a hard time hearing and then she yelled at me. When RN B tried to diffuse the situation and separate Resident R6 and RN G away from each other, RN G stated, It's not ok, no one really understands it's really not ok. RN B confirmed she helped report the incident to the NHA.Camera footage was reviewed with the NHA on 11/20/25 at 2:20 p.m. Registered Nurse (RN) G and Resident R6 were observed on camera, in the hallway and RN G was with Resident R6 crouching down, with her finger pointed at Resident R6 and coming within inches of Resident R6's face. RN G was observed standing up and turning around, before quickly turning back to Resident R6 still sitting in the hallway and getting very close to Resident R6's face again. Two staff members come into the hallway with one approaching Resident R6 while RN G goes off camera.An interview was conducted with Resident R6 on 11/20/25 at 2:45 p.m. Resident R6 stated

she has a very difficult time hearing but does not need staff to yell at her for her to understand.Review of

the facility's Abuse Prevention Program read, in part, Our residents have the right to be free from abuse.as part of the resident abuse prevention, the administration will: Implement measures to address factors that may lead to abusive situations.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

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

Facility ID:

If continuation sheet

Event ID:

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

11/21/2025

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 0602

Protect each resident from the wrongful use of the resident's belongings or money.

Level of Harm - Actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility failed to protect the residents right to be free of misappropriation of property by staff. This deficient practice resulted in psychosocial harm based on the reasonable person perspective. Findings include: This citation pertains to intake: 2615537Resident #5 (Resident R5)Review of Resident R5's Electronic Medical Record (EMR) revealed admission to the facility on 7/2/25 and discharge on [DATE REDACTED].

Review of Resident R5's medical diagnosis included metabolic encephalopathy (brain dysfunction caused by chemical imbalance).On 8/30/25, Family Member N was visiting Resident R5 who was actively dying at the facility and stayed until approximately 3:30 a.m. Family Member N noted during the visit, Resident R5 had her gold wedding band and solitaire diamond band on her fingers. Family Member N returned to the facility at approximately 12:00 p.m. on 8/30/25 and continued to sit with Resident R5 until her death at 12:45 p.m. Family Member N requested Resident R5's rings be given to him before she was taken to the funeral home. It was at this time Family Member N and staff noted the rings were missing from Resident R5's fingers. Family Member N reported this to the floor nurse and Nursing Home Administrator (NHA) and a search was conducted. Local police were contacted and had begun an investigation into whether Resident R5's missing wedding rings were misappropriated.On 8/31/25, Licensed Practical Nurse (LPN) O spoke to Family Member N and stated one of Resident R5's wedding rings had been recovered when Certified Nurse Aide (CNA) I returned the ring after being questioned by police in connection to the investigation.An interview was conducted with Registered Nurse (RN) P on 11/21/25 at 12:00 p.m. RN P confirmed one missing ring was returned by CNA I after being questioned by police. RN P stated CNA I was only in Resident R5's room for approximately a minute before exiting with one ring. CNA I stated she found the ring stuck in the wheel of Resident R5's bed. RN P stated only one ring was retrieved of two that were missing.An interview with Detective Q on 11/21/25 at 10:50 a.m. confirmed local police were involved in the alleged misappropriation of Resident R5's wedding rings. Detective Q stated, upon investigation, CNA I admitted to the misappropriation of the wedding rings and was arrested on the morning of 8/30/25.An interview was conducted with CNA I who confirmed she did steal Resident R5's rings on 8/30/25 after Family Member N had left the facility. CNA I confirmed she did try and plant one of Resident R5's rings in her room

after an investigation had begun.An interview was conducted with the NHA on 11/21/25 at 2:00 p.m. The NHA stated that Family Member N requested Resident R5's wedding rings continue to stay on her finger while staying at the facility. NHA stated that Family Member N recognized that Resident R5 would be devastated if her wedding rings were not there. Review of the facility's ‘Abuse Prevention Program' policy read, in part, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation.

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

11/21/2025

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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

juice and 17 g polyethylene glycol or 10 mg bisacodyl tabs. Review of Resident R7's progress notes and electronic medication administration dated 10/23/25 through 11/21/25 revealed no documentation of interventions or GI assessments related to bowel protocol. On 11/21/25 at 10:00 AM, an interview was conducted with the Director of Nursing (DON), who was asked what their expectations were for nursing to follow through with bowel protocol and replied, 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. The DON was asked if nursing was following bowel protocol where they should be documenting an intervention and replied, Nurses should be documenting on the medication administration

record or in the progress notes. The DON confirmed that both Resident R3 and Resident R7 had lacked expected documentation showing nurses had been following bowel protocol. The DON agreed intervention not documented were considered not done. The DON was asked for a bowel management policy and replied,

The facility does not have a policy on bowel management. Nursing is to follow bowel protocol.

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

11/21/2025

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 0686 Level of Harm - Actual harm Residents Affected - Few

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

covered with an abdominal pad.11/20/25 at 4:21 PM, read in part Update recieved [sic] from.local ER [emergency room].admitted d/t (due to) decubitus ulcer on his buttock. Surgery is seeing him tomorrow. Will probably mostly end up with a wound vac and IV (intravenous) anx (antibiotic) therapy.Noted to have hyperglycemia, increased lactic acid, and hyponatremia (low sodium). WBC (white blood cell count) 16.8 [elevated].Review of policy titled, Pressure Ulcer/Skin Breakdown - Clinical Protocol, dated June 2023, read

in part, Assessment and Recognition 1. The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcer; for example, immobility, recent weight loss, and history of pressure ulcer(s). 2. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; b. Pain assessment; c. Resident's mobility status; d. Current treatments, including support surfaces.

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

11/21/2025

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 0697 Level of Harm - Actual harm Residents Affected - Few

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

with RN F who was asked how long Resident R7 was experiencing pain during wound dressing changes and replied, For a month and it has become worse in the last week or two. During an interview on 11/21/25 at 12:45 PM with the Director of Nursing (DON) who was asked about pain assessments for Resident R7 and why nursing was not completing the pain assessments over the last month when staff verbalized that Resident R7's pain was present

during wound dressing changes and increased extensively over the last week. The DON stated, Pain assessments should be completed each shift. There should be an order in place for nursing to complete a pain assessment. I am not sure why there is not an order to do so. If he (Resident R7) was having pain, then nursing should have at least been giving acetaminophen from the standing orders and if that did not help then the provider should have been contacted related to pain during dressing changes. The DON agreed that a premedication prior to dressing changes would be beneficial for Resident R7.Review of policy titled, Pain Assessment and Management, date revised March 2015, read in part, Purpose: Support consistent pain assessment and documentation and promote safe treatment and follow up. General Guidelines.2. Complete

a pain assessment each shift for any resident with pain.3. Use the o to 10 subjective pain scale for residents who self-report.6. Document all findings.Responsibilities: Nurse 1. Complete all pain assessments.6. Notify the provider of uncontrolled pain.8. Reassess after interventions. 9. Update the care plan when needed.

Event ID:

Facility ID:

If continuation sheet