Cedar Crest Nursing: Infection Control Failures - CA
The nurse, identified in inspection records only as LVN N, had been repositioning Resident 95 in his bed. She then picked up a Fluticasone nasal spray and administered it to the resident's nostrils. The gloves she wore during the repositioning never came off. Her hands were never sanitized.
When inspectors spoke with LVN N about what they had observed, she acknowledged she should have cleaned her hands and changed gloves before giving the nasal spray. She offered no explanation for why she hadn't.
The facility's director of staff development, who also serves as its infection prevention consultant, told inspectors on August 8 that licensed nurses are expected to sanitize their hands and change gloves before administering eye drops or nasal sprays to residents. The facility's own written medication policy, dated January 2023, lists hand hygiene as a required step in the nasal drop procedure.
The policy existed. The training existed. Neither stopped what inspectors watched happen.
A separate problem turned up the same week in a bathroom shared by four residents across two adjoining rooms. On the morning of August 5, inspectors found a collection of personal care items sitting unlabeled in the shared space: a pink plastic wash basin, a bedpan, two urinals, and a kidney-shaped basin that held a toothbrush and a half-used tube of toothpaste.
A certified nursing assistant, identified as CNA K, was present during the observation. She confirmed that none of the items were labeled with a resident's name or room number. She confirmed they were all currently in use, not new supplies waiting to be assigned. Four residents were sharing that bathroom. Without labels, she said, there was a real risk of using one resident's bedpan or toothbrush basin for another.
A bedpan collects feces and urine from a resident who cannot get out of bed. A urinal collects urine. The kidney-shaped basin is used for mouth care. All of it, unlabeled, in a room used by four people.
The infection prevention consultant told inspectors the items should have been labeled before staff ever put them into use. She said nursing staff were responsible for doing that labeling. The facility's own policy on bedpans and urinals, though undated, states plainly that all such items will be marked with a resident's name for individual use.
Again, the policy existed. Again, it wasn't followed.
Inspectors rated both violations at the level of minimal harm or potential for actual harm, affecting some residents. Cedar Crest did not receive an immediate jeopardy citation from this inspection. But the findings describe something more corrosive than a single lapse: a gap between what a facility's written procedures require and what its staff actually do when no one is watching.
Resident 95 had a nurse lean over him, reposition his body with gloved hands that had touched whatever they had touched, and then press a medication applicator into his nostrils. He did not choose that. He could not prevent it. Whether he knew it happened is not recorded in the inspection report.
The four residents sharing that bathroom had their most intimate care items sitting in a communal space, indistinguishable from one another. Whose toothbrush basin was whose. Whose urinal. The certified nursing assistant who cared for them knew it was a problem. She said so to inspectors. The items stayed unlabeled anyway, until someone from the outside came to look.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cedar Crest Nursing and Rehabilitation Center from 2025-08-11 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.
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Last verified: November 3, 2026 · Our methodology
CEDAR CREST NURSING AND REHABILITATION CENTER in SUNNYVALE, CA was cited for violations during a health inspection on August 11, 2025.
The nurse, identified in inspection records only as LVN N, had been repositioning Resident 95 in 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.