Alden Estates of Countryside: Medication Error Harms Resident - WI
Federal inspectors cited Alden Estates of Countryside following a complaint inspection in November 2025, finding that the facility failed to clarify, transcribe, and follow a physician order for a medication called Levetiracetam, sold under the brand name Keppra. The citation carried a finding of actual harm.
The resident, identified in inspection records as R2, had been prescribed Keppra for seven days as a seizure prophylaxis, meaning it was intended as a short-term preventive measure, not an ongoing treatment. The facility kept giving it anyway.
When surveyors pressed staff about why the medication continued, the answers were thin. The Director of Nursing, identified as DON B, said they were unsure when a neurology review was even scheduled. The facility's Registered Nurse Coordinator, identified as RNC C, said they could not speak to whether a neurologist had been consulted about safely stopping the drug, and added that the neurologist had not been the one to originally order it.
That last point turned out to be contested by the records themselves. The hospital discharge summary showed that neurology had in fact been consulted and had provided recommendations. RNC C's account did not match what was in the paperwork the hospital had already sent over.
Keppra is not a medication to be continued carelessly. It is prescribed to control seizures, and when given beyond its intended course or without proper monitoring, it can cause serious neurological and metabolic effects. R2's hospitalization record listed the diagnosis as acute metabolic encephalopathy, described as multifactorial, with the continued use of Keppra identified as a contributing cause. The resident required intravenous fluids, monitoring, and discontinuation of the drug.
That is the clinical translation of what the facility's error produced: a resident's brain function deteriorating to the point that they needed to be readmitted to a hospital and treated with IV fluids before the medication they should never have still been taking was finally stopped.
RNC C acknowledged to surveyors that the facility had investigated the discrepancy between the hospital orders and the facility's own orders once it was brought to their attention. But when surveyors asked for documentation of that investigation, the facility could not provide any. There was nothing to show.
The gap between what staff said happened and what the records could support was a thread running through the entire inspection finding. The hospital said neurology weighed in. The facility said it couldn't speak to that. The facility said it investigated the medication discrepancy. The records said otherwise.
Medication order transcription errors in nursing homes are not rare, but the chain of failures here extended well beyond a single clerical mistake. Someone had to be administering the medication each day it continued. Someone had to be signing off on the medication administration record. The order that should have ended the Keppra course either was never properly entered, was entered and ignored, or was never clarified with the prescribing physician in the first place. The inspection finding does not specify which, and the facility's inability to produce investigation records means the internal accounting, if it ever happened, left no trace.
DON B did not know when a neurology follow-up was scheduled. That uncertainty, offered to federal surveyors after a resident had already been hospitalized from the error, suggests the facility had not moved with urgency even after R2 came back from the hospital.
R2 returned to a hospital for a condition that listed the facility's own medication mismanagement as a cause. The hospitalization required IV fluids and monitoring. The drug was discontinued. Whether R2 recovered fully, the inspection report does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Alden Estates of Countryside, Inc from 2025-11-25 including all violations, facility responses, and corrective action plans.
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: August 23, 2026 · Our methodology
Alden Estates of Countryside, Inc in JEFFERSON, WI was cited for violations during a health inspection on November 25, 2025.
The citation carried a finding of actual harm.
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.