The January incident at Evergreen Post Acute began when Staff 33, a nurse, found several bottles of methadone in Resident 3's medication lock box. She estimated each bottle contained 2 to 4 ml of the opioid addiction treatment medication.
"She could not read the labels on the bottles because they were smeared," according to the federal inspection report. Staff 33 opened all the bottles anyway.
When she reached the last two bottles, Staff 33 realized there wasn't enough methadone to equal the 20 ml daily dose prescribed for Resident 3. She asked Staff 9, another nurse, what to do.
Staff 9 questioned why Staff 33 had opened all of the resident's methadone bottles. Staff 33 insisted the physician's order was wrong — that it should have been for 2 ml, not 20 ml.
Staff 9 confirmed the order was indeed for 20 ml.
The two nurses went to Resident 3's room to explain the situation. The resident "slumped to the floor because she/he was upset," Staff 33 told inspectors.
What Staff 33 didn't know was that Resident 3 had already received their daily methadone dose that morning at an off-site clinic.
Staff 38, a respiratory therapist, witnessed the confusion around 8:19 AM. He saw Staff 9, Staff 33 and Resident 3 "huddled near the entrance to his office." Both Staff 9 and Resident 3 were upset because Staff 33 had opened all the methadone bottles.
"Resident 3 was concerned she/he would not be able to get her/his dose of methadone that day and Staff 9 promised she would take care of it," Staff 38 reported.
Staff 38 escorted Resident 3 to the methadone clinic and watched as the resident took their dose. The resident had already received their prescribed 20 ml of methadone for the day.
But the medication mix-up wasn't over.
Around 10:48 AM, new methadone was delivered to the facility. At 11:00 AM, Staff 33 went to Resident 3's room with another dose.
"Resident 3 stated are you sure I haven't received this already and Staff 33 answered no so Resident 3 took the dose," according to the inspection report.
Staff 5, an RN consultant, confirmed that at 11:51 AM on January 10, Resident 3 received an extra dose of methadone after returning from the methadone clinic. The resident had now received 40 ml of methadone that day — double their prescribed amount.
Staff 33 later told inspectors she administered the extra dose "because staff did not communicate to her that Resident 3 went to the methadone clinic earlier in the day and received a dose at the clinic."
When Staff 38 provided a breathing treatment to Resident 3 later that day, he noted "there was no change from her/his baseline after the resident received the second dose."
The incident reveals a breakdown in communication and medication management protocols at the Portland facility. Staff 33 made multiple decisions that led to the overdose: opening bottles with unreadable labels, questioning a correct physician's order, and administering medication without verifying whether the resident had already received their daily dose.
Methadone is a powerful synthetic opioid used to treat addiction to heroin and other opioids. Double dosing can cause dangerous respiratory depression, especially in elderly patients who may have other health conditions.
The resident's question — "are you sure I haven't received this already" — suggests they were aware of the potential for duplication, but Staff 33's assurance led them to take the second dose.
Federal inspectors found the facility failed to ensure medications were administered safely and according to physician orders. The violation was classified as causing minimal harm or potential for actual harm to a few residents.
The inspection report does not indicate whether Resident 3 experienced any adverse effects from receiving double their prescribed methadone dose, beyond the initial distress that caused them to slump to the floor when learning their medication bottles had been opened.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Evergreen Post Acute from 2025-11-17 including all violations, facility responses, and corrective action plans.