Pomeroy Living Rochester: Sepsis Death After Lab Failures - MI
The sequence of failures that preceded that transfer, documented by federal inspectors who completed a complaint survey on August 28, 2025, centered on two things happening at the same time: staff who didn't recognize or report the signs of a urinary tract infection, and a contracted laboratory so dysfunctional that the facility's own Director of Nursing had already begun documenting its failures before the resident ever got sick.
The resident, identified in inspection records as R202, had been newly admitted to the facility. When symptoms appeared that pointed to a UTI, they were not reported to a physician or nurse practitioner. No antibiotic treatment was started. A complete blood count and a comprehensive metabolic panel, basic tests that would have shown whether infection had spread into the bloodstream, were either never ordered or never completed. Inspectors reviewed the record and found no results. The Director of Nursing reviewed the record and could not find results either.
By the time R202 reached the hospital, the infection had become sepsis. Sepsis had become septic shock. The kidneys had begun to fail. A hospitalist's consult note, dated August 22, 2025, described lactic acidosis, hematuria, and a change in mental status. The note documented that R202 had been admitted to the intensive care unit, received fluid resuscitation and vasopressors, and been evaluated by a multidisciplinary team. Despite all of it, the resident continued to decline.
The hospitalist wrote that R202 "has had acute renal failure on presentation" and that the patient "has declined to decline despite maximal medical therapy." After a meeting with the palliative care team and a hospice informational visit, the vasopressors keeping R202's blood pressure from collapsing were discontinued. The note described shallow breathing, persistent low blood pressure, and minimal urine output. R202 was transferred to inpatient hospice. The family member had been consulted and understood, the hospitalist wrote, "the grave prognosis."
The Director of Nursing, interviewed by inspectors on August 27, 2025, described walking into a facility already in trouble. They were newly employed. They had recognized early on that there were problems with the contracted laboratory. They had already started documenting what they called a "past non compliance" related to laboratory services, specifically delayed completion and delayed reporting of test results. At the time of the interview, they were trying to find a new laboratory provider.
That context makes what happened to R202 not an isolated accident but a foreseeable consequence of a known, unresolved problem. The lab was broken. The Director of Nursing knew it. The facility had not yet replaced it. And when a newly admitted resident developed signs of infection, the results that might have prompted faster treatment either never came back or came back too late to matter.
The Director of Nursing acknowledged the concern when inspectors raised it directly. They explained that staff had been waiting for lab results before starting treatment. They also offered a second explanation: because R202 was newly admitted, staff didn't know what the resident's baseline looked like, and so they may not have recognized that something had changed.
That explanation points to a second, separate failure. The facility's own policy on acute changes in condition, dated July 2021, states that residents are assessed upon admission to establish baseline data, that any staff member who notices a change communicates it to nurses, and that changes in condition are communicated to the physician. The policy exists precisely because new admissions are vulnerable, precisely because staff need a documented baseline to recognize deviation from it. The policy did not protect R202.
Inspectors rated the violation at the level of actual harm, meaning the failures were not theoretical. The harm had already happened. R202 was already in hospice by the time the survey was completed.
What the inspection report does not answer is how long the symptoms were present before anyone acted, or whether earlier intervention could have changed the outcome. Sepsis, when caught early, is treatable. When it progresses to septic shock and multiorgan failure despite intensive care, the window has long since closed. The hospitalist's note described maximal medical therapy that wasn't enough.
The Director of Nursing, to their credit, did not deflect. They acknowledged the lab problem. They acknowledged they had known about it. They acknowledged the failure to report symptoms to a physician. What they could not provide, by the end of the survey, was any documentation showing what had been done for R202 in the days before the transfer, or why the basic blood work had never been completed.
Inspectors noted that no further explanation or documentation was provided before the survey closed.
Pomeroy Living Rochester Skilled Rehabilitation is a skilled nursing and rehabilitation facility located at 3500 West South Blvd in Rochester Hills. The complaint survey that produced this finding was completed August 28, 2025.
The family member who spoke with the hospitalist in the ICU, who agreed to the plan of care, who understood the grave prognosis, is not named in the inspection report. Neither is R202. What the record preserves is the hospitalist's clinical summary, a Director of Nursing who arrived at a facility already failing and hadn't yet finished fixing it, and a resident who came to a skilled nursing facility for rehabilitation and was transferred to inpatient hospice instead.
The shallow breathing. The minimal urine output. The pressors discontinued.
The family member who understood.
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.
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: July 2, 2026 · Our methodology
Pomeroy Living Rochester Skilled Rehabilitation in Rochester Hills, MI was cited for immediate jeopardy violations during a health inspection on August 28, 2025.
The resident, identified in inspection records as R202, had been newly admitted to the facility.
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.