Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Boulder Park Terrace
Charlevoix, MI · 72 certified beds · Last Life Safety survey June 5, 2025
CMS Certification Number 235526 · first certified August 1992
Ownership
Independently operated (no chain recorded by CMS) · Non profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within MI
26 citations — more than 84% of the 422 certified nursing homes in MI. Compared within MI rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 13 citations; the earlier surveys in the window averaged 6.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (May 2026 to July 2026), and past the point by which nine in ten MI facilities have been surveyed. This facility’s last Life Safety survey was June 2025. Facilities in MI are typically surveyed 12–14 months after the last one (median 13), measured over 723 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
Get an email about Boulder Park Terrace
One email when it happens. No account; stop it any time with one click.
1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
4 of the 26 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
5 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 26 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
How that compares
Compared with the median facility in MI, and nationally. Surveyors differ markedly between states, so the MI figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 26 |
| Median facility in MI | 14 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| June 8, 2023 | 6 |
| May 15, 2024 | 7 |
| June 5, 2025 | 13 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0920 | Ensure proper usage of power strips and extension cords. | 3 | 2025-06-05 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 3 | 2025-06-05 |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | 2 | 2024-05-15 |
| K-0293 | Have properly located and lighted "Exit" signs. | 1 | 2024-05-15 |
| K-0232 | Have corridors or aisles that are unobstructed and are at least 8 feet in width. | 1 | 2025-06-05 |
| K-0231 | Provide large enough exits. | 1 | 2023-06-08 |
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | 1 | 2025-06-05 |
| E-0039 | Conduct testing and exercise requirements. | 1 | 2025-06-05 |
What the citations cover
- Smoke Deficiencies 8
- Egress Deficiencies 6
- Emergency Preparedness Deficiencies 4
- Gas, Vacuum, and Electrical Systems Deficiencies 4
- Other 4
| Category | Citations |
|---|---|
| Smoke Deficiencies | 8 |
| Egress Deficiencies | 6 |
| Emergency Preparedness Deficiencies | 4 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 4 |
| Miscellaneous Deficiencies | 2 |
| Services Deficiencies | 2 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
June 5, 2025 — 13 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (July 7, 2025) |
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (July 7, 2025) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (July 22, 2025) |
| K-0232 | Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Deficient, Provider has date of correction (July 7, 2025) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (July 7, 2025) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (July 7, 2025) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (July 7, 2025) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (July 7, 2025) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (July 7, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (July 7, 2025) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (July 7, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (July 7, 2025) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (July 7, 2025) |
May 15, 2024 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0029 | Develop a communication plan. | Deficient, Provider has date of correction (June 14, 2024) |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (June 14, 2024) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (June 14, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (June 14, 2024) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (June 14, 2024) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (June 26, 2024) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (June 14, 2024) |
June 8, 2023 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (July 10, 2023) |
| K-0231 | Provide large enough exits. | Deficient, Provider has date of correction (July 10, 2023) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (July 10, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (July 10, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (July 10, 2023) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (July 10, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.