Resident 41 told inspectors on March 3 that Rocky Mountain Care - Cottage on Vine didn't have enough staff and that he wasn't receiving his IV antibiotics on time. His medical conditions included polyneuropathy, type 2 diabetes, osteomyelitis, non-pressure chronic ulcer, gas gangrene, cutaneous abscess of the left foot, and cellulitis.
The patient required two powerful IV antibiotics to fight his severe infections. Daptomycin was ordered at 750 milligrams daily at 1:00 PM. Micafungin was scheduled for 100 milligrams daily at 10:00 PM.
But medication records showed a pattern of missed doses that stretched across two weeks in February.
The Daptomycin arrived late on February 13 at 3:29 PM — more than two hours after the 1:00 PM order. On February 18, the antibiotic wasn't administered until 4:01 PM, three hours late. February 22 brought another delay to 2:52 PM, nearly two hours behind schedule. On February 25, the medication was given at 2:55 PM, almost two hours after the prescribed time.
The evening antibiotic fared worse. Micafungin was supposed to arrive at 10:00 PM but showed up on February 14 at 2:38 PM the next day — more than 16 hours late. February 16 brought a delay until 2:55 PM, again more than 16 hours behind schedule. On February 18, the drug finally arrived at 6:08 PM, eight hours late.
Two doses in late February pushed well past midnight. On February 23, the 10:00 PM medication wasn't given until 11:48 PM — nearly two hours late. February 25 saw the antibiotic administered at 11:43 PM, more than an hour behind the ordered time.
No records existed showing that physicians were notified about any of these delays.
RN 3 explained the facility's policy during a March 4 interview. The nurse said medications could be given 30 minutes before or after the scheduled time and still be considered on time. Anything beyond that window should trigger a call to the physician.
"If the antibiotic was not given on time she would notify the physician," according to the inspection report.
But the medication records showed delays stretching far beyond 30 minutes, with some doses arriving more than 16 hours late.
The Director of Nursing confirmed the policy during a March 6 interview. Antibiotics had a 30-minute window before or after the scheduled administration time. Beyond that, physicians needed notification.
"The physician needed to be notified if the medication was not administered per the ordered schedule," the DON told inspectors. "Staff should have notified the physician of the delay in treatment."
The facility's failure created a dangerous gap in communication. When antibiotics are delayed, doctors need to know immediately so they can adjust treatment plans or order additional interventions. Gas gangrene, one of the resident's conditions, is a rapidly spreading infection that can be life-threatening without prompt treatment.
The inspection revealed a breakdown in basic medication management. Staff understood the policy requiring physician notification for late medications. The DON confirmed that doctors should have been called about the treatment delays. Yet no documentation existed showing these critical communications ever happened.
For Resident 41, fighting multiple serious infections including gas gangrene and osteomyelitis, every hour mattered. His IV antibiotics were specifically ordered to maintain consistent blood levels needed to combat these aggressive infections.
The pattern of delays wasn't isolated to a single day or shift. Records showed problems spanning two weeks, affecting both the 1:00 PM and 10:00 PM medications. Some delays stretched the dosing intervals far beyond the prescribed 24-hour schedule, potentially compromising the antibiotics' effectiveness.
The resident's own assessment proved accurate. He told inspectors the facility lacked adequate staffing and that his antibiotics weren't arriving on time. The medication records validated his concerns, showing systematic failures in one of the most basic nursing responsibilities.
Federal inspectors cited the facility for failing to ensure residents received medications as prescribed and for not notifying physicians of significant delays. The violation affected medication management protocols that are fundamental to resident safety.
Rocky Mountain Care's staff knew the rules but failed to follow them when a diabetic patient with gas gangrene needed his life-saving antibiotics on schedule. The resident waited hours for medications that should have arrived within a 30-minute window, while his doctors remained unaware that his treatment was falling dangerously behind.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Rocky Mountain Care - Cottage On Vine from 2025-03-06 including all violations, facility responses, and corrective action plans.
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