Meadowbrook Manor Naperville: Resident Left in Feces - IL
The resident, identified in inspection records only as R1, is obese, incontinent of both bowel and bladder, and cannot reposition herself without two staff members helping her. She had been at the facility less than a week when inspectors arrived on September 2, 2025.
The certified nursing assistant on her unit, identified as V6, told inspectors her shift had started at 6 a.m. She had not provided incontinence care or turned the resident at any point before 11:55 a.m., nearly six hours into her shift. V6 said the wound nurse had handled incontinence care during a dressing change. That was the only care R1 had received.
R1 said the same thing. V6 had not provided any incontinence care during her shift.
When inspectors examined R1, they found dried feces packed between her gluteal fold. The skin of her labia and gluteal fold was reddened. On her coccyx, there was a small open area, a pressure wound that the wound nurse, identified as V3, said she had first discovered and documented on August 29, two days after R1 arrived. The wound measured 2.0 centimeters long, 0.2 centimeters wide and 0.2 centimeters deep. There had been no documentation of the wound in R1's hospital discharge records, and none on the day she was admitted.
R1 was also on antibiotics for a urinary tract infection.
At some point during the morning, R1 had called her family. A family member, identified as V8, told inspectors she had called him more than once asking him to call the nursing station for help. On one of those calls, she told him she had been left in a soiled brief for more than two hours.
She was calling her family to reach her nurses.
The wound nurse was direct about what the situation required. V3 told inspectors that R1's obesity and incontinence made skin breakdown a specific and known risk, and that nursing staff were responsible for repositioning her and providing incontinence care. Moisture, she said, was a contributing factor in the wound that had already opened on R1's coccyx.
The facility's own incontinence care policy, dated April 2025, states that incontinence care is provided to keep residents dry, comfortable, and odor free, and to prevent skin breakdown. Its wound prevention policy, also from April 2025, calls for cleaning skin at the time of soiling and at routine intervals, and requires a prevention plan for every new admission based on the resident's condition and risk.
R1 had an open wound. She had a UTI. She could not move herself. She needed two people to reposition her. She had been at the facility for five days.
The administrator, identified as V1, told inspectors that residents should not need to call their family members to get staff assistance.
That was not disputed. It also did not change what had happened that morning, or the mornings before it. The inspection report does not describe what, if anything, had been done differently in the days between R1's admission and the morning inspectors arrived. It does not say whether anyone had checked on her before 11:55 a.m. on previous days, or whether the wound on her coccyx had grown since V3 first measured it on August 29.
What the report says is that a woman who could not clean herself, could not turn herself, and could not get anyone to come to her room spent the better part of a morning lying in her own waste, with broken skin on her tailbone, calling her family for help.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Meadowbrook Manor - Naperville from 2025-09-03 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 30, 2026 · Our methodology
MEADOWBROOK MANOR - NAPERVILLE in NAPERVILLE, IL was cited for violations during a health inspection on September 3, 2025.
She had been at the facility less than a week when inspectors arrived on September 2, 2025.
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.