Health inspection·September 3, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was applied two days prior to the incident. Following this report on Resident #99 we did a full house assessment and no residents had any changes in their status. The Fentanyl patch was on a totally different part of the facility on a different cart, with different staff. Review of the investigation conducted by and provided by the facility documented:1. 8/28 resident was transferred to the hospital following an unresponsive episode around 2:12 p.m.2. On 8/29/25 around 3:30 p.m., a detective arrived at the facility to discuss the incident. Reported that the resident tested positive for fentanyl on 8/28, detective reported that the results came back at 5:11 p.m., on 8/28/25, resident left facility before 2:30 p.m.3. On 8/29 the Director of Nursing (DON) reviewed narcotic disposal and dispense sheets to verify all medications in order. Verified narcotic disposal and procedure is being followed.4. On 8/29 the DON and nursing team completed a full head to toe assessment on all residents.5. 8/29 DON completed in-service with education with nursing team throughout the weekend on drug disposal policy.6. 8/30 DON and Admin met with weekend supervisor and on shift providing additional education.7. 9/2/25 Detective returned to the facility and met with the clinical team on shift 8/28/25 interviewing them.8. 8/29 DON completed in-service with education with nursing team throughout the weekend on drug disposal policy.9. 9/2/25 the Detective returned to the facility and met with the clinical team on shift 8/28/25 interviewing them. On 9/3/25 at 11:75 a.m., in an interview Licensed Practical Nurse (LPN) Staff A said the resident was sitting in the common area and was yelling he wanted to go to bed but the CNA 's (certified nursing assistant) were putting other residents to bed. He had therapy and when they came to take him down to the therapy room, he was unresponsive. The CNA's were hoping the therapists would put him back to bed when they were done but when they came to get him he was unresponsive.Therapy called for myself and the nurse who works with me. We tried to arouse him; he was breathing but shallow. Staff B went with them to put him in bed, and I went to check his code status and call 911. They gave us instructions to lay him flat and elevate his feet, remove the pillow. His oxygen saturations were good but we did start oxygen because his breathing was shallow. It was roughly about 10 minutes between the time he was found and the time he went out of the facility with EMS. He was his normal self, and he was awake when EMS came and they transferred him. They did not say what was wrong with him and I did not see them give him any medications. He was awake once we laid him down. Once they leave the facility, they usually transfer them right away. He never had an issue like this before. He had no opioids he had no narcotics. I gave him medications but no opioids, he did not have any. On 9/3/25 at 12:17 p.m., in an interview Registered Nurse (RN) Staff B said I was here the day the resident was sent to the ER. We were at the nursing station when the therapist came and said someone was unresponsive and we went to the common area. The resident was in the w/c in front of the television. He was not responding, and I did the sternal rub, his eyes rolled back, and he did the puff breathing. I said let's get him to his room and we were checking his status. The aides got vital signs and we got the crash cart. I applied oxygen and we placed him in bed in the Trendelenburg position. He was in and out, of responding. LPN Staff A was calling 911. I left to get the transfer papers once he started to respond. I did not see EMS administer any medications to the resident. Honestly, once they arrived, I moved out of the way so they could do their job and take over. On 9/3/25 at 1:17 p.m., in an interview the DON, said I was there the day EMS came and the resident was unresponsive. His pupils were small, but I would not say they were pinpoint. I'm a cardiac nurse and the resident has a cardiac history, he had a syncope episode. When he got into the room he was responding, yelling and confused but that was his usual. On 9/3/25 at 1:25 p.m., in an interview the AED said the resident did not leave the facility. He had no other visitors and no appointments. I did not interview the staff because when the officer came, she conducted all the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105396 If continuation sheet Page 2 of 3 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105396 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chateau at Moorings Park, The 130 Moorings Park Drive Naples, FL 34105 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm interviews while I was there. I have no written interviews, I did not do it, the police have them. On 9/3/25 at 2:00 p.m., during an exit interview, the Executive Director argued that she did not feel the event required reporting because they did not know where the fentanyl came from. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105396 If continuation sheet Page 3 of 3