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Negligent care resulted in a dramatic outbreak of hepatitis C at an HCR ManorCare nursing home in North Dakota last year, residents allege in a federal lawsuit filed Wednesday.

Forty-four people were infected at the 114-bed facility in Minot last August. Improper foot care, nail care or blood services might have caused the outbreak, according to health officials quoted by The Associated Press. However, no official cause has been pinpointed. A North Dakota Department of Health investigation is ongoing.

HCR ManorCare issued a statement that the lawsuit is premature, considering the origin of the outbreak has not been established. The Ohio-based provider says it has been “cooperative and proactive” in reviewing and following infection control practices, and is working with authorities to ensure resident and employee safety.

Even though an exact cause has not been confirmed, the “most rudimentary of care” would have prevented the infections, plaintiff attorney Mike Miller told the AP.

Two residents — 78-year-old John Fenner and 84-year-old Lilas Guttormson — brought  the suit in U.S. District Court in Bismarck. They are seeking unspecified monetary damages and class action status. 

The outbreak accounted for a quarter of all hepatitis C cases nationally since 2008, according to the Centers for Disease Control and Prevention. Hepatitis C causes chronic liver damage and can be fatal. While injection drug users are at the greatest risk, the disease can be spread from needlestick injuries or when needles or syringes are reused in a healthcare setting.

None of the infected residents died due to the disease, but all are still coping with its effects, the AP reported.