Alden Estates of Naperville: Wound Care Mattress Failure - IL
The wound care nurse who discovered the problem on August 30 said she believed the resident had the correct mattress when he arrived. After a room transfer on August 24, nobody made sure it followed him.
The resident, identified in inspection records only as R1, came to the facility with multiple wounds already present on admission. A wound physician examined him on August 18 and documented two stage 2 pressure injuries: one on his left buttock measuring 0.7 centimeters by 0.7 centimeters, and one on his right buttock measuring 0.7 centimeters by 0.5 centimeters. The consultation report ordered a low air loss mattress as part of his wound management plan. The order was active. The mattress was not there.
By the morning of August 30, the wound care nurse found both injuries open, with minor bleeding and irritation to the surrounding skin. The left buttock wound had grown to 3 centimeters by 2 centimeters. That is more than seventeen times its original surface area. The right buttock wound measured 0.6 centimeters by 0.6 centimeters, also larger than when first documented.
The wound care nurse said she was concerned because the wound showed signs of deterioration, as evidenced by the increase in size. She said she was unsure why R1 was not currently provided with his ordered specialized mattress. She said wound care management interventions should be followed as ordered to prevent skin and wound deterioration.
What made the gap harder to explain was that the wound physician had been back on August 25, the day after the room transfer, and documented measurements that were actually smaller than on admission. The left buttock wound had shrunk to 0.5 centimeters by 0.5 centimeters. The right had dropped to 0.4 centimeters by 0.5 centimeters. That visit came and went. Five days later, the wounds were significantly larger, and the mattress was still missing.
The Director of Nursing, interviewed that same afternoon, said wound care interventions should be implemented as ordered, including an air loss mattress.
The resident's care plan, updated on August 25, listed pressure redistribution support in bed as an active intervention. His order summary, pulled the morning of August 30, showed the low air loss mattress order had been active for two weeks. The paperwork said one thing. The bed said another.
A low air loss mattress is not a comfort upgrade. It works by continuously cycling air through the surface beneath a patient, reducing the sustained pressure on bony areas that causes pressure injuries to form and deepen. For a resident already managing two open wounds on his buttocks, a standard mattress does the opposite of what treatment requires. Every hour spent on the wrong surface works against the care his physician ordered.
The inspection, conducted on August 30 and August 31, 2025, was a complaint investigation. Inspectors reviewed three residents with pressure injuries and cited this failure for one of them.
Nobody in the inspection report explained how a mattress order active since August 16 went unexecuted through a room transfer, through a physician follow-up visit five days later, and into the sixth day after the move. The wound care nurse said she was unsure. The Director of Nursing said interventions should be implemented. The resident's wounds, in the meantime, had grown.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Alden Estates of Naperville from 2025-08-31 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.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
ALDEN ESTATES OF NAPERVILLE in NAPERVILLE, IL was cited for violations during a health inspection on August 31, 2025.
The wound care nurse who discovered the problem on August 30 said she believed the resident had the correct mattress when he arrived.
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.