Willow Valley Center: Resident Left in 3 Soiled Briefs - NC
The woman had activated her call light at 8:15 a.m. asking to be changed, but nursing assistant told her she had to wait because breakfast trays were arriving. When the assistant delivered her meal tray, the resident asked again to be changed. The assistant again refused, saying she would be changed after breakfast.
The resident told inspectors she felt "dirty, angry and neglected."
When inspectors observed staff finally changing the resident at 11:33 a.m., they found bowel movement and urine had seeped through all three briefs, the draw sheet, cotton pad, and fitted sheet. Feces had dried to the woman's skin, creating dark yellow rings on her bedding.
The nursing assistant who eventually provided care said seeing three briefs on a resident was "not normal practice" and that the condition suggested the resident hadn't been changed since the night before.
Nobody investigated.
The facility administrator learned of the resident's feelings of neglect on June 12, but never completed an initial allegation report to state regulators as required within two hours. Six days later, the administrator told inspectors she still hadn't investigated why the resident was wearing three briefs or reported the neglect allegation to the state.
"No resident should have to eat their meal in a soiled and wet brief," the Director of Nursing told inspectors.
The dignity violation was one of 18 deficiencies federal inspectors documented during their July 2024 survey. The facility also failed to provide basic nail care, missed critical medical appointments, and violated medication safety rules that left residents without prescribed treatments for weeks.
Medications Missing for Weeks
Resident #416 went 20 doses without his prescribed antifungal powder because staff never obtained the over-the-counter medication from their pharmacy. The man had been discharged from a hospital with orders to apply miconazole powder twice daily for dry skin covering his body.
The medication was ordered May 30 but never arrived on his medication cart. For nearly two weeks, nurses simply marked on his medication record that the powder wasn't available rather than investigating why.
The facility's Central Supply clerk said she wasn't notified about the over-the-counter medication order until June 12 — the day inspectors arrived. The dispensing pharmacy confirmed they don't provide over-the-counter medications and had received no inquiry from the facility about the missing powder.
"We would document if there had been an inquiry by the facility about whether a medication would be sent out by the pharmacy," the pharmacy representative said. No such documentation existed.
Psychotropic Drugs Without Limits
Two residents received powerful psychotropic medications on an as-needed basis for months without the required 14-day time limits or clinical justification for extended use.
Resident #97 had been given diazepam — a controlled substance — every eight hours as needed for "crying and/or anxiety" since February 23, with no end date. The facility's consultant pharmacist flagged this violation four separate times between November 2023 and May 2024, recommending that extended orders require documented clinical rationale and duration limits.
Only one of those four recommendations received a physician response, which failed to address either the duration or rationale requirements.
Resident #28 received Haloperidol every six hours as needed for agitation starting May 8, also without a stop date. The medication administration records showed she received 16 doses over five weeks.
The nurse practitioner who wrote the order told inspectors she knew psychotropic medications required 14-day limits but had failed to include the stop date.
Critical Appointments Missed
A resident with latent tuberculosis missed her infectious disease clinic appointment because the facility's wheelchair van malfunctioned the morning of March 11. The appointment coordinator said she typically rescheduled missed appointments within a day or two, but this resident was never rescheduled before being discharged to the hospital two days later.
The resident told inspectors by phone that she was informed the van wasn't working and her appointment would be rescheduled, but it never was.
"The Resident Appointment Coordinator should have rescheduled the appointment in a timely manner," the administrator acknowledged.
Oxygen Safety Ignored
Resident #176 received continuous oxygen therapy but had no warning signs posted outside her room for over a month. The unit supervisor discovered the missing signage only after the Director of Nursing specifically asked her to check for oxygen warning signs during the inspection.
The resident had been moved from one room to another about a month earlier, but staff never transferred the required safety signage.
Mental Health Screenings Delayed
Three residents with new mental health diagnoses never received required screening updates that could affect their level of care and services. One resident diagnosed with post-traumatic stress disorder in March had demonstrated increasingly aggressive behavior, including swinging his cane at staff and using racial slurs, but was never referred for updated psychiatric evaluation.
The social worker responsible for submitting screening requests said she was "behind" and had "a stack of referrals" on her desk. She was the only person with access to the state screening system.
Kitchen Contamination Risks
The facility's dishwasher failed to maintain proper sanitizing solution levels, potentially exposing residents to contaminated dishes. When inspectors tested the chlorine sanitizer, it registered zero parts per million instead of the required 50 ppm.
Four of the facility's 10 meal delivery carts had been missing doors for three months, leaving food exposed during transport. The dietary manager acknowledged that shepherd's pie and vegetables served to residents were "lukewarm and bland" during taste testing.
Kitchen equipment was covered in grease and food debris. Two dietary staff worked with exposed facial hair ranging from half an inch to one inch in length without required hair coverings.
Structural Safety Hazards
Handrails throughout three floors were loose, detached from walls, or had sharp exposed edges where end caps were missing. Staff and residents continued using the damaged handrails for support during the inspection.
The maintenance director said he was aware of the problems but had no system to monitor or prioritize handrail repairs. He presented an invoice for replacement parts dated the day inspectors arrived.
The resident who endured breakfast in three soiled briefs represents a broader pattern of care failures documented throughout the facility. Her experience of being told to wait while sitting in her own waste — because meal service took priority — captures the fundamental dignity violations that federal inspectors found embedded in the facility's daily operations.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Willow Valley Center For Nursing and Rehabilitatio from 2024-07-02 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
Willow Valley Center for Nursing and Rehabilitatio in Winston-Salem, NC was cited for violations during a health inspection on July 2, 2024.
The woman had activated her call light at 8:15 a.m.
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.