Alden Estates: Wound Care Mattress Failures - IL
The wound care nurse at Alden Estates of Naperville discovered the problem during her August 30 assessment. She found the resident on a standard mattress despite active orders for low air loss equipment dating back to August 16.
The nurse measured wounds that had grown significantly worse. The left buttock injury now measured 3 centimeters by 2 centimeters, compared to 0.7 by 0.7 centimeters when first documented on August 18. The right buttock wound measured 0.6 by 0.6 centimeters, up from 0.4 by 0.5 centimeters just five days earlier.
Both wounds showed signs of deterioration. They remained open with minor bleeding and displayed peri-wound irritation around the damaged tissue.
The wound care nurse told inspectors she was concerned about the resident's condition. She said the wounds showed "signs of deterioration today, as evidenced by an increase in size measurement."
She believed the resident had received an air loss mattress when he was first admitted. But he had been moved to a different room on August 24, and she was "unsure why" he was not currently provided with his ordered specialized mattress.
The resident's wound physician had been clear about the treatment requirements. An August 18 consultation report included a specific order for a low air loss mattress as part of the wound management plan. The facility's own records showed this order remained active through August 30.
The Director of Nursing confirmed that wound care interventions should be implemented as ordered, including the air loss mattress.
Meanwhile, the resident's care plan acknowledged he was "at risk for further skin breakdown due to his multiple wounds." The plan included an intervention for pressure redistribution support specifically initiated on August 25 - five days before inspectors found him on the wrong mattress.
The facility's own policies emphasized the importance of following treatment protocols. One policy stated that residents "who have been assessed as in need of a low air loss mattress will have a mattress set up for their use." Another required staff to "implement preventative measures and appropriate treatment modalities for pressure injuries."
The timeline reveals a troubling pattern. The resident arrived with multiple pressure injuries present on admission. His doctor ordered specialized equipment on August 16. The facility created a care plan intervention on August 25. Yet on August 30, he remained on standard bedding while his wounds grew larger.
Air loss mattresses work by providing continuous airflow through small holes in the surface, reducing pressure on vulnerable areas and helping prevent further tissue damage. For residents with existing pressure injuries, these specialized surfaces are considered essential equipment to prevent deterioration.
The wound care technician who assisted with the assessment confirmed the resident required daily dressing changes as part of his treatment regimen. But without the proper mattress support, those daily interventions were insufficient to prevent the wounds from worsening.
The resident had been moved rooms on August 24, six days before the inspection. That room change appears to have disrupted his care plan, leaving him without the specialized mattress his condition required.
Federal inspectors cited the facility for failing to provide appropriate pressure ulcer care and prevent new ulcers from developing. The violation was classified as causing minimal harm or potential for actual harm.
The wound care nurse's concern proved justified. In less than two weeks, the resident's left buttock wound had grown from less than half a centimeter to 3 centimeters across - more than four times its original size.
The inspection found that wound care management interventions "should be followed as ordered to prevent skin and wound deterioration." The facility had the orders, the policies, and the equipment requirements clearly documented.
What it failed to provide was the mattress itself.
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.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 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 at Alden Estates of Naperville discovered the problem during her August 30 assessment.
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.