Elevate Health and Rehabilitation: Seizure Med Failures - NC
Federal inspectors cited the facility for immediate jeopardy, the most serious category of nursing home violation, following a complaint inspection completed September 2, 2025.
The medication was lacosamide, a controlled substance used to manage seizure disorders. The resident, identified in inspection records only as Resident 98, had returned to the facility from a hospital stay on January 4, 2025. According to the facility's administrator, the hospital had sent her back with a three-day supply. After that ran out, what followed was ten days of miscommunication, missed steps, and an assumption that someone else had handled it.
Nobody had.
The administrator, who did the most talking during an interview with inspectors on August 28, 2025, laid out the sequence herself. The pharmacy did not have a prescription to refill the lacosamide. Nursing staff believed the pharmacy had one. A nurse called the pharmacy and was told the medication was coming. When it did not come, a physician gave an order to hold the medication until it arrived from the pharmacy. During the hold period, another call went to the pharmacy. The medication was coming, staff were told again.
On the morning of January 14, the lacosamide still was not there. Medical Director 1 happened to be inside the building that morning, and Nurse 1 went to him about it. He sent a prescription to the pharmacy. Later that same morning, Resident 98 had a seizure. Medical Director 1 went to her and tried to stop it at the facility. He could not. EMS was called.
The facility's medical director, identified as Medical Director 3 in inspection records, was interviewed separately. He described Resident 98's seizure disorder as complicated, and said it would be hard to identify a precise number of missed doses that would trigger a seizure because she had seizures even while on her medications. He could not recall when her last seizure before January 14 had occurred. He said an infection she had at the time likely contributed to the seizure and that the complications she was experiencing made it more severe.
Then he said this: nine missed doses of lacosamide would lower her seizure threshold, making her more likely to have a seizure. He said he thought the missed doses may have contributed to her having a seizure. He said he did not think her not getting the lacosamide was "alright by any means."
The administrator did not soften what happened either. She called the missed doses a significant medication error. She said nursing was not following processes at the time. She said the assigned nurse was responsible for contacting the provider for a prescription when a medication was running low, and that when the lacosamide did not arrive, the nurse should have escalated the situation to the director of nursing or management. She said it should have been caught in the facility's morning clinical meetings, which were typically attended by the director of nursing, the unit manager, and a staff development coordinator.
She said she believed it had been mentioned in a morning clinical meeting that the lacosamide was unavailable. But because a physician had issued a hold order, staff assumed the physician was aware and the medication was on its way. That assumption held for ten days.
The administrator said lacosamide was not stocked in the facility's backup medication system. She said the nurse should have been persistent in obtaining the controlled prescription. "It was their duty as a nurse to obtain it," she said.
She also said there had not been good oversight by the former director of nursing and that clinical meetings had not been thorough. That was why, she told inspectors, management changes had been made and why corporate management had come into the building.
The director of nursing present during the August 28 interview said she had not been the director of nursing in January.
Inspectors notified the facility of immediate jeopardy on August 27, 2025, at 5:40 in the evening. The facility submitted a corrective action plan with a correction date of January 22, 2025, eleven days after Resident 98 was taken away by ambulance.
What the inspection report does not contain is any account of what happened to Resident 98 at the hospital, how long she was there, or what her condition was when she returned. It does not say whether she sustained lasting harm from the seizure. It does not say whether anyone at the facility was disciplined. The corrective action plan is cut off in the inspection record before its contents are fully described.
What it does contain is a medical director's acknowledgment that nine missed doses of a seizure medication in a patient with a complicated seizure disorder lowered her threshold for having one, and an administrator's acknowledgment that the system failed at every level where it could have caught the problem: the nurse who should have escalated, the morning meetings that should have flagged it, the management that should have been watching.
Elevate Health and Rehabilitation is a nursing and rehabilitation facility in Asheville. The inspection was conducted in response to a complaint.
Resident 98 went nine days between returning from the hospital and the morning a doctor inside her own building sent a prescription to the pharmacy. She had a seizure before it arrived.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Elevate Health and Rehabilitation from 2025-09-02 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 27, 2026 · Our methodology
Elevate Health and Rehabilitation in Asheville, NC was cited for violations during a health inspection on September 2, 2025.
The medication was lacosamide, a controlled substance used to manage seizure disorders.
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.