Willow Valley Nursing: Soiled Socks Left On Resident - NC
Federal inspectors documented the finding during a complaint inspection that concluded August 29. The resident, identified in inspection records only as Resident #4, was admitted to the facility with dementia and an enlarged prostate, and uses an indwelling catheter with a leg bag attached. His cognitive impairment was assessed as severe. He requires substantial assistance with toileting and personal hygiene. His care plan specifically instructs staff to make sure his shoes are comfortable and not slippery.
At 11:20 in the morning on August 25, an inspector watched him walk out of his bedroom wearing yellow socks with purple stripes. Both socks were saturated with liquid. His plaid pajama pants were soaked down the back of his right leg. Wet footprints trailed from his room. On the floor at the foot of his bed, there was a small wet area surrounded by more footprints.
He was still wearing the same yellow socks the next morning.
On August 26 at 9:30 a.m., inspectors observed him lying in bed in a hospital gown, the yellow socks still on his feet, now with light brown stains on the bottoms. Nearly two hours later, at 11:25 a.m., he was still in bed, still in the same socks. It wasn't until August 27, when an inspector returned at 8:40 a.m., that he was wearing something different: gray sweatpants and gray nonskid footies.
The nursing assistant who put the yellow socks on him the morning of August 25 told inspectors she removed those same socks the morning of August 27. She said she wasn't assigned to him on August 26 and didn't know what had happened in between.
A second nursing assistant said she put gray socks on him on August 26, after lunch, and placed his soiled clothing in a bag in the soiled linen room. She said she couldn't remember what socks he was wearing before she changed him.
The unit manager said she hadn't known the resident wore the same pair from August 25 through August 27. She said the second nursing assistant had told her she changed his socks on August 26. The unit manager also explained that the resident sometimes disconnected his leg bag from the catheter, and that staff had implemented frequent checks because of it.
Nobody's account adds up cleanly. If the second nursing assistant changed his socks on August 26, the yellow pair should not have still been on him when inspectors returned that same morning, and again two hours later. The nursing assistant who put them on says she took them off two days after she applied them. The unit manager learned what the inspectors found only after they found it.
The Assistant Director of Nursing told inspectors he did not know why the resident would have worn the same socks for multiple days in a row. He said staff had been instructed to replace the resident's socks as needed. He said he would follow up with the unit manager and reinforce the importance of proper footwear with unit staff.
Reinforce the importance of proper footwear. The phrase sat in the inspection record beside the image of a severely cognitively impaired man, unable to advocate for himself, walking down a nursing home hallway in socks heavy with his own urine, wet prints marking every step.
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.
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
Willow Valley Center for Nursing and Rehabilitatio in Winston-Salem, NC was cited for violations during a health inspection on August 29, 2025.
Federal inspectors documented the finding during a complaint inspection that concluded August 29.
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.