Cedar Crest Nursing: Infection Control Failures - CA
The infection control violation occurred at Cedar Crest Nursing and Rehabilitation Center during federal inspectors' complaint investigation in August. LVN N acknowledged during questioning that she should have cleaned her hands and changed gloves before giving Resident 95 the Fluticasone nasal spray.
The facility's own medication policy requires hand hygiene before administering nose drops. The director of staff development confirmed that licensed nurses must sanitize their hands and change gloves before giving eye drops or nasal sprays to residents.
But hand hygiene wasn't the only infection control problem inspectors found.
In a shared bathroom serving four residents, inspectors discovered unlabeled personal care equipment scattered throughout the space. A pink wash basin, bedpan, two urinals, and a kidney-shaped mouth care basin sat without any identification marking which resident they belonged to.
One of the mouth care basins contained a toothbrush and half-used tube of toothpaste.
Certified nursing assistant K confirmed all the items were currently in use, not new equipment waiting to be assigned. The aide acknowledged that without labels, staff risked using the care items for the wrong resident.
"There is risk of using these care items for unassigned resident," CNA K told inspectors.
The bathroom served residents in rooms A and B. None of the personal care equipment bore resident names or room numbers, despite facility policy requiring all bedpans and urinals to be marked with the resident's name for individual use.
The director of staff development and infection prevention consultant stated that nursing staff should have labeled the care items before using them. The facility's own policy on cleaning bedpans and urinals specifies that "all bed pans and urinals will be marked with resident's name for individual use."
Federal inspectors classified both violations as having minimal harm or potential for actual harm to residents. The medication administration failure affected some residents at the facility.
The violations represent basic breakdowns in infection control protocols designed to prevent the spread of disease between vulnerable nursing home residents. Cross-contamination from shared personal care items or contaminated hands during medical procedures can lead to serious infections in elderly patients with compromised immune systems.
LVN N's failure to change gloves between repositioning a resident and administering nasal medication created a direct pathway for transferring bacteria or other pathogens from the patient's body to their nasal passages. Nasal sprays enter sensitive mucous membranes where infections can easily take hold.
The unlabeled bathroom equipment posed ongoing risks. Without proper identification, staff could inadvertently use one resident's bedpan or wash basin for another patient, potentially spreading urinary tract infections, skin conditions, or other communicable diseases throughout the facility.
Cedar Crest's infection prevention consultant acknowledged both problems violated established protocols. The facility had written policies covering both situations but failed to ensure staff followed them consistently.
The August inspection was conducted in response to a complaint about conditions at the Sunnyvale facility. Inspectors found that basic infection control measures required by federal nursing home regulations were not being implemented by frontline staff.
Both violations occurred despite the facility having appropriate policies in place. The medication administration policy clearly outlined hand hygiene requirements, while the bedpan cleaning policy specifically mandated individual labeling of equipment.
The breakdown appeared to be in implementation rather than policy development. Staff members demonstrated awareness of proper procedures when questioned but had not followed them in practice.
For nursing home residents, who often have weakened immune systems and multiple chronic conditions, even minor infection control lapses can have serious consequences. Respiratory infections from contaminated nasal medications or urinary tract infections from shared bathroom equipment can quickly become life-threatening in frail elderly patients.
The inspection found that some residents were affected by the medication administration violations, though the report did not specify how many patients received medications from staff who failed to follow proper hand hygiene protocols.
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.
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 21, 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 infection control violation occurred at Cedar Crest Nursing and Rehabilitation Center during federal inspectors' complaint investigation in August.
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.