Pomeroy Living Rochester: UTI Missed, Resident in Hospice - MI
The resident, identified in inspection records only as R202, had been newly admitted to Pomeroy Living Rochester Skilled Rehabilitation on West South Boulevard when she began showing clinical signs of a urinary tract infection. The symptoms were not reported to the facility's physician or nurse practitioner. No treatment was started. The nursing staff, according to the Director of Nursing, was unaware that anything had changed because R202 was new and they didn't know what her baseline looked like.
That explanation did not satisfy federal inspectors who arrived at the facility on August 28, 2025, following a complaint.
What they found was a cascade of delays, each one compounding the last. Lab work had been ordered but results were not coming back in any reasonable time. A urinalysis with culture and sensitivity, the standard test for identifying a UTI and determining which antibiotic will treat it, was delayed. Basic bloodwork, a complete blood count and a comprehensive metabolic panel, was apparently ordered at some point but the results could not be located. The Director of Nursing told inspectors she had read a note indicating the tests were pending. She could not find the results.
Nobody had them.
By the time R202 received care, she had deteriorated to the point that she required transfer to an intensive care unit. Her blood pressure had dropped. She was lethargic. Her urine output was minimal. Whatever infection had taken hold in the days after her admission to Pomeroy had moved well beyond the stage where a course of antibiotics and close monitoring might have been enough.
She was transferred from the ICU to inpatient hospice. The inspection record notes that a family member had been spoken with, both during the ICU admission and afterward, and was agreeable with the plan of care and understood what the record calls "the grave prognosis." At the time inspectors documented their findings, R202 had shallow breathing and remained hypotensive.
The Director of Nursing, who told inspectors she was newly employed at the facility herself, did not minimize what had happened. She acknowledged the concern when inspectors raised it directly. But her explanation for why the infection had gone unrecognized and untreated traced back to two separate problems, one involving the staff and one involving the lab.
On the staff side, she said the nursing team simply didn't know R202 well enough to recognize that her condition had changed. The resident was new. There was no established baseline in the staff's working knowledge of her. The facility's own policy on acute changes in condition, dated July 2021, states that residents are assessed upon admission to establish baseline data and that any change in symptoms is to be communicated to a nurse and then to the physician. The policy defines an acute change of condition as a sudden deviation from baseline that, without intervention, may result in complications or death.
R202's symptoms were not communicated to the physician. No intervention came in time.
On the lab side, the Director of Nursing described something that appeared to be a known and ongoing problem. She told inspectors that upon arriving at Pomeroy, she recognized there were issues with the contracted laboratory. She had already started documenting past noncompliance related to laboratory services. The specific problem she identified was delayed completion and reporting of test results. By 9:02 on the morning of August 27, 2025, she told inspectors she was actively trying to find a new laboratory provider for the facility.
That conversation happened the day before the inspection concluded. The search for a new lab was still underway.
The implications of what the Director of Nursing described are worth sitting with. She came into a facility, recognized that the lab it depended on for test results was not performing reliably, began documenting the problem, and was working to find a replacement. All of that is, in isolation, the right set of responses. But in the meantime, residents were still being tested through that same contracted laboratory. Results were still being delayed. And at least one of those residents, a newly admitted woman whose infection went unrecognized in part because her lab work didn't come back, ended up in an ICU and then in hospice.
The Director of Nursing acknowledged, when asked directly, that R202's clinical signs and symptoms of a UTI had not been initially reported to the physician or nurse practitioner. She acknowledged the failure to timely identify and treat the infection. Her explanation, that staff was waiting for lab results before starting treatment, points to a choice that inspectors clearly found inadequate given how sick the resident became.
Urinary tract infections in elderly and medically fragile patients are not minor inconveniences. Left untreated, they can progress to sepsis, a condition in which the body's response to infection begins damaging its own tissues and organs. Hypotension, lethargy, and minimal urine output, the symptoms documented in R202's case, are consistent with a body under severe systemic stress.
The inspection report classifies the level of harm as actual harm. The number of residents affected is listed as few.
That last word, few, is the kind of bureaucratic understatement that tends to disappear in regulatory filings. It does not disappear when you read what happened to R202. It does not disappear when you read that the Director of Nursing, in describing the lab problem, was not talking about something she discovered the week before. She was talking about a pattern she identified when she walked in the door, a pattern serious enough that she began formally documenting it as past noncompliance.
How many lab results were delayed before R202 was admitted is not stated in the inspection record. How many residents had tests ordered and waited longer than they should have for results is not stated. What is stated is that the Director of Nursing knew the system was broken and was working to replace it, and that during that window, a woman came in, got sick, and wasn't treated in time.
Inspectors noted that no further explanation or documentation was provided by the end of the survey.
R202's family had been told the prognosis was grave. She was in inpatient hospice, breathing shallowly, her blood pressure still low.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pomeroy Living Rochester Skilled Rehabilitation from 2025-08-28 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Pomeroy Living Rochester Skilled Rehabilitation in Rochester Hills, MI was cited for violations during a health inspection on August 28, 2025.
The symptoms were not reported to the facility's physician or nurse practitioner.
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.