Willow Valley Center: Resident Wore Soiled Socks 3 Days - NC
Federal inspectors observed Resident #4 on August 25 wearing yellow socks with purple stripes that were "saturated with a liquid substance." His plaid pajama pants were also soaked down the back of his right leg. Wet footprints led from his bedroom door to a puddle at the foot of his bed.
The next morning, inspectors found the same resident lying in bed still wearing the identical yellow socks, now stained light brown on the bottom. He wore those same socks again on August 26.
Resident #4 suffers from severe dementia and requires substantial assistance with basic hygiene tasks. He has an indwelling catheter with a leg bag that he sometimes disconnects, according to staff interviews. His care plan specifically instructs staff to "make sure shoes are comfortable and not slippery."
Nursing Assistant #1 told inspectors she put the yellow socks on the resident the morning of August 25. She wasn't assigned to him on August 26, she said. But she removed those same yellow socks on August 27 — meaning the resident wore soiled footwear for at least 48 hours.
The story gets more confusing from there.
Unit Manager #1 claimed she wasn't aware the resident had worn the same socks for multiple days. She said Nursing Assistant #2 told her she had changed the resident's socks on August 26.
But Nursing Assistant #2 told inspectors she put gray socks on the resident that day. She couldn't remember what socks he had been wearing before she dressed him after lunch. She said she put his soiled clothing in a bag and placed it in the soil linen room.
The contradictory accounts suggest staff either weren't communicating about basic care tasks or weren't performing them at all.
Resident #4 was admitted to the facility with dementia and an enlarged prostate. His quarterly assessment revealed he was severely cognitively impaired but showed no behavioral problems or rejection of care. He needed substantial help with toileting hygiene and moderate assistance with personal hygiene.
Despite these documented needs, staff allowed him to walk around in saturated socks that left visible wet prints on the floor. The facility's own care plan called for ensuring his footwear was appropriate and safe.
The Assistant Director of Nursing told inspectors that staff were instructed to replace the resident's socks as needed. He said he didn't know why the resident would wear the same socks for multiple days. He promised to follow up with the unit manager and reinforce proper footwear protocols with staff.
But the damage was already done. For three days, a vulnerable resident with severe dementia walked around in his own waste while multiple staff members either failed to notice or failed to act.
The facility implemented frequent checks to prevent the resident from disconnecting his catheter leg bag, according to the unit manager. Yet somehow staff missed the obvious signs that his socks were soaked with liquid and needed immediate changing.
Medication Aide #1 noted that the resident "normally lets staff groom him," suggesting he wasn't resistant to care. The failure to provide clean socks appears to be purely a matter of staff neglect or poor communication.
The inspection found wet footprints surrounding a puddle at the foot of the resident's bed, indicating the problem had persisted long enough to create multiple trips across the contaminated area. The resident's pajama pants were also saturated, showing the extent of the hygiene failure.
Federal inspectors classified this as minimal harm, but the violation reveals broader problems with basic care standards. A facility that can't ensure clean socks for a compliant dementia patient raises questions about what other daily care tasks might be overlooked.
The resident's care plan specifically addressed his need for comfortable, non-slip footwear due to his cognitive impairment and mobility needs. Staff ignored their own written protocols while allowing a vulnerable patient to walk around in conditions that posed both dignity and safety concerns.
Three different nursing staff members gave conflicting accounts of who was responsible for the resident's care on which days, suggesting poor coordination of basic hygiene tasks among the care team.
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 2025-08-29 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 August 29, 2025.
Wet footprints led from his bedroom door to a puddle at the foot of his bed.
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.