Boulder Park Terrace: Patient Assaulted Staff, Police - MI
The violent incident unfolded during a two-day stay at Boulder Park Terrace in July. The patient, identified in inspection records as R2, had been admitted on July 8 with diagnoses including restlessness, agitation, adult failure to thrive, and anorexia.
By July 10, the situation had escalated dramatically.
According to progress notes written by facility staff, the patient "not only assaulted staff but assaulted a police officer." Staff documented that he was "refusing meds, refusing care, dumping his urinal, shouting the F word, assaulting staff." The notes indicate police removed him from the facility in handcuffs and transported him to the emergency room.
The patient's wife learned about the overnight chaos through a morning phone call from facility staff. Progress notes show she "was very surprised on all that was replayed to her this am of the occurrences from last night." Staff had been unable to reach her the previous evening, unable to leave voicemails on her phone.
During that morning conversation, facility staff told the wife that her husband "does not get along in a group setting" and "would not be able to continue staying here." They explained they needed "to be able to actually care for him" but he was refusing all assistance.
The wife agreed to take her husband home if the facility could provide transportation. Staff arranged for a transporter to bring him back to his residence that same day. He left with his wheelchair, walker, and other belongings, though staff noted they were unable to locate his glasses and would check with the emergency room next door.
Despite this dramatic discharge involving police intervention and assault allegations, Boulder Park Terrace failed to complete a recapitulation of stay for the patient. This document, required by federal regulations, summarizes a resident's time at the facility and their condition at discharge.
Federal inspectors who reviewed the case in August found no recapitulation of stay in the patient's electronic medical record. The facility's nursing home administrator confirmed during an interview that the required documentation was never completed.
The facility's own discharge policy clearly outlines these requirements. According to the policy reviewed by inspectors, when a facility anticipates discharging a resident to a private residence, "a discharge summary and post-discharge plan will be developed which will assist the resident to adjust to his or her new living environment."
The policy specifically states that "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."
This documentation serves a critical purpose beyond regulatory compliance. Discharge summaries help receiving caregivers understand what medical care and interventions a patient received, what medications they were prescribed, and what ongoing needs they might have.
For a patient with documented behavioral issues serious enough to result in police intervention and assault charges, such documentation becomes even more crucial for ensuring continuity of care and safety planning.
The inspection was conducted as part of a complaint investigation, suggesting someone reported concerns about the facility's handling of the situation. Federal inspectors classified the violation as causing "minimal harm or potential for actual harm" and affecting "few" residents.
However, the case raises questions about Boulder Park Terrace's ability to handle residents with complex behavioral needs and its compliance with basic administrative requirements during crisis situations.
The facility's progress notes reveal a chaotic situation where staff struggled to manage a combative patient while attempting to communicate with family members. The notes suggest the patient's behavior escalated to the point where staff felt unable to provide care safely.
Yet even in emergency discharge situations, federal regulations require facilities to complete proper documentation to ensure patient safety and care continuity. The missing recapitulation of stay represents a failure in this fundamental responsibility.
The patient's brief stay illustrates the challenges nursing homes face when caring for residents with severe behavioral issues. However, proper discharge planning and documentation remain essential regardless of the circumstances surrounding a resident's departure.
Boulder Park Terrace's failure to complete required paperwork for a patient who left in police custody suggests gaps in administrative procedures during crisis situations.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Boulder Park Terrace from 2025-08-14 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 August 14, 2025.
The violent incident unfolded during a two-day stay at Boulder Park Terrace in July.
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.