Elevate Health and Rehabilitation: Seizure Med Failures - NC
Federal inspectors cited the facility for immediate jeopardy, the most serious classification available under Medicare's inspection system, following a complaint investigation completed in September 2025. The violations center on a single resident, identified in inspection records only as Resident 98, and a cascade of missed steps that stretched over at least ten days in January.
The medication was lacosamide, a controlled substance used to treat seizure disorders. Resident 98 returned to the facility from a hospital stay on January 4, 2025. According to the administrator, the hospital had sent her back with a three-day supply. After that ran out, the pharmacy had no prescription on file to refill it. Nursing staff believed the pharmacy had one. The pharmacy believed a prescription was coming. Nobody had one.
When the lacosamide didn't arrive, a nurse called the pharmacy and was told the medication was on its way. When it still didn't arrive, rather than escalating to management or pressing the physician for an emergency supply, the nurse obtained an order to simply hold the medication until it came. The hold order created the appearance that the situation was being handled. It wasn't.
The facility's morning clinical meetings, which the administrator said were typically attended by the director of nursing, the unit manager, and the staff development coordinator, were where this should have surfaced. The administrator told inspectors she believed the missing lacosamide had been mentioned in one of those meetings. The conclusion the group reached, apparently, was that because a physician had signed off on the hold order, the physician was aware, and the medication was in transit. Neither assumption was correct.
By the morning of January 14, eleven days after Resident 98 had returned from the hospital, her lacosamide was still not in the building. That morning, a physician happened to be on-site. Nurse 1 approached him about it. He sent a prescription to the pharmacy. A few hours later, before the medication arrived, Resident 98 seized.
The physician was still in the building. He tried to stop the seizure at the facility. He could not. EMS was called. Resident 98 was transported to the hospital.
The facility's medical director, identified in the report as Medical Director 3, told inspectors he could not recall when Resident 98 had last seized before January 14. He acknowledged that nine missed doses of lacosamide would lower her seizure threshold, making a seizure more likely. He noted she had also developed an infection, which he believed contributed to the severity of what happened. He said he did not think her missing the lacosamide "was alright by any means." He also said he thought the missed doses may have contributed to the seizure, while noting she was on other seizure medications and that her disorder was complicated enough that it was hard to pinpoint exactly how many missed doses would trigger an event.
That last point did not soften what inspectors found. The question was not whether lacosamide alone caused the seizure. The question was whether nine missed doses of a prescribed controlled substance for a resident with a known seizure disorder represented a serious medication error. The administrator, speaking for the facility during an interview on August 28, answered that directly. She called it "a significant medication error."
The administrator's account of what went wrong was detailed, and in some ways, damning. She said the assigned nurse was responsible for contacting the prescribing physician when a medication needed to be renewed, and for doing so before the supply ran out. That did not happen. She said when the medication failed to arrive from the pharmacy, the nurse should have escalated the situation to the director of nursing or another manager. That did not happen either. She said the morning clinical meeting should have caught it. She believed it was mentioned but that the team assumed the hold order meant things were under control.
She also said lacosamide was not stocked in the facility's backup medication system, the emergency supply that nursing homes typically maintain for situations exactly like this one, where a controlled substance runs out and a new prescription takes time to arrive. There was no bridge. There was no fallback.
The administrator did not deflect. She said nursing staff were not following processes at the time, that the former director of nursing had not provided adequate oversight, and that clinical meetings had not been thorough. She said those failures were why management changes had been made and why corporate leadership had been brought into the building. The director of nursing present during the August interview told inspectors she had not been in the role in January.
Inspectors were notified of the immediate jeopardy finding on August 27, 2025, at 5:40 in the evening. The facility submitted a corrective action plan with a correction date listed as January 22, 2025, nearly eight months before inspectors arrived.
What the inspection report does not contain is what happened to Resident 98 after EMS took her from the building on January 14. Her condition at the hospital, the duration of her stay, whether she recovered fully or sustained lasting harm from the seizure, none of that appears in the records inspectors made public. The report describes a woman whose medication ran out, whose nurses assumed someone else had handled it, whose morning meetings noted the problem and moved on, and who seized in a facility where the one medication that might have helped her was sitting in a pharmacy waiting for a prescription that took eleven days to materialize.
The medical director said her seizure disorder was complicated. He said her infection made things worse. He said it was hard to say exactly how many missed doses would have been enough to push her over the edge.
Nine, it turned out, was enough.
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.
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Last verified: November 8, 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 treat 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.