Evansville Manor: Clozapine Overdose Harms Resident - WI
On August 26, 2025, a resident at Evansville Manor Nursing and Rehab had a change in condition after receiving the wrong dose of Clozapine, an antipsychotic medication that requires careful monitoring because of how quickly it can become dangerous. Her blood pressure climbed. Her heart rate rose. Her oxygen level dropped. She was hard to wake.
Staff did none of what her provider had asked.
The nurse practitioner, identified in inspection records only as NP C, told inspectors she had no idea any of it had happened. She had given the facility explicit instructions: contact her or the psychiatric team if there were any changes in the resident's mental status or vital signs. When inspectors asked whether she would have expected staff to report a change of condition like the one that occurred that day, she said yes, she would have expected to be told. And if she had been told, she said, she would have sent the resident to the emergency room.
Instead, no one called. The facility did not complete ongoing comprehensive assessments of the resident, identified in the inspection report as R2, despite the visible changes in her alertness and vital signs. The deterioration was documented in the record. The provider was not notified.
R2 was eventually sent to the hospital. The cause was accidental overdose of Clozapine.
Clozapine is not a medication with much margin for error. It is prescribed for serious psychiatric conditions, typically when other medications have failed, and it carries significant risks at elevated blood levels, including sedation, respiratory depression, and cardiovascular instability. The symptoms R2 showed on August 26, the difficulty waking, the blood pressure and heart rate changes, the declining oxygen, are consistent with what a clinician would expect to see when the drug reaches toxic levels. NP C knew that. That is why she had asked for close monitoring and had told staff to reach out with any changes.
The facility's failure here was not a single missed step. It compounded. Someone gave the wrong dose. Then, as the resident's condition changed in ways that were visible and measurable, staff did not assess her comprehensively. Then, having failed to assess her, they did not report what they were seeing to the provider who had specifically requested that information. NP C, who could have intervened and said so plainly to inspectors, was left without the information she needed to act.
Inspectors cited the deficiency at the "actual harm" level, meaning the failure caused real injury to a real person, not a theoretical risk. The citation falls under F0684, which addresses the standard of care nursing facilities owe residents.
Evansville Manor sits on Garfield Avenue in Evansville, a small city in Rock County. The complaint inspection was completed September 17, 2025.
What the inspection record does not contain is what happened after R2 reached the hospital, how long she was there, what treatment she required, or what her condition was when she left. The record ends where the facility's responsibility became someone else's problem to fix.
NP C had asked for close monitoring. She had been specific. She had left instructions. When inspectors sat down with her and described what her patient had gone through on August 26, she told them she had no idea that situation had occurred.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Evansville Manor Nursing and Rehab, LLC from 2025-09-17 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: September 17, 2026 · Our methodology
EVANSVILLE MANOR NURSING AND REHAB, LLC in EVANSVILLE, WI was cited for violations during a health inspection on September 17, 2025.
Staff did none of what her provider had asked.
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.