McClure Post Acute: Medication Security Failure - CA
The breathing medication sat unsecured on Resident 76's tray table at McClure Post Acute when federal inspectors arrived in April. The facility's own policy requires all drugs to be stored in locked compartments.
Resident 76 suffers from acute and chronic respiratory failure with hypoxia — his body struggles to get enough oxygen. The albuterol sulfate inhaler helps make breathing easier by opening his airways.
When inspectors found the medication during their April 6 visit at 4:33 p.m., they asked the resident about it directly.
"It was getting annoying asking the nurse when I need my puffer," he told them. So he kept the medication at his bedside instead.
Twenty-two minutes later, inspectors confronted Licensed Vocational Nurse 2 about the unsecured inhaler. The nurse confirmed the medication was left on the bedside table and acknowledged that "medication shouldn't be left unsecured at bedside."
The Director of Nursing agreed three days later during an interview on April 9. The albuterol inhaler "should not have been left unsecured at Resident 76's bedside," the DON confirmed.
McClure Post Acute's own medication storage policy, dated November 2020, is explicit: "The facility stores all drugs and biological in a safe, secure, and orderly manner. Drugs and biologicals used in the facility are stored in locked compartments."
The policy assigns clear responsibility to nursing staff for "maintaining medication stores and preparation areas in a clean, safe, and sanitary manner."
Federal inspectors determined the violation created potential for "unsafe or unauthorized medication use, drug diversion, and accidental ingestion by Resident 76 or other medically vulnerable residents."
Albuterol inhalers contain medication that can affect heart rate and blood pressure. In the wrong hands or wrong dosage, the drug can cause dangerous side effects including rapid heartbeat, chest pain, and tremors.
The inspection found McClure Post Acute failed to ensure medications were stored safely for one of 19 residents whose cases were reviewed. But the single violation represents a breakdown in basic medication security protocols that nursing homes are required to maintain.
Nursing facilities must balance resident autonomy with safety requirements. Some residents receive permission to self-administer certain medications under specific circumstances, but this requires formal assessment and documentation of the resident's ability to manage their drugs safely.
No such assessment or authorization appears in the inspection record for Resident 76.
The facility's medication policy requires locked storage for all drugs and biologicals used in the facility. Federal regulations mandate that nursing homes maintain secure medication systems to prevent diversion, accidental ingestion, and unauthorized use.
Respiratory medications like albuterol are particularly concerning when left unsecured. Residents with dementia or cognitive impairment might not understand the proper dosage or could accidentally ingest medications belonging to others.
McClure Post Acute has operated in Oakland for years, serving residents who require post-acute care and rehabilitation services. The facility treats patients with complex medical conditions, many of whom depend on multiple medications to manage their health.
The April inspection focused on medication management practices across the facility. Inspectors reviewed policies, interviewed staff, and observed medication storage and distribution procedures.
The violation was classified as causing "minimal harm or potential for actual harm" and affected "few" residents. But medication security failures can escalate quickly in facilities serving medically vulnerable populations.
Resident 76's frustration with asking nurses for his inhaler highlights staffing and accessibility issues that can lead residents to circumvent safety protocols. When getting necessary medication becomes "annoying," residents may take matters into their own hands.
The inspection report doesn't indicate whether the facility has corrected the medication storage violation or implemented additional safeguards to prevent similar incidents.
For Resident 76, whose body already struggles to get enough oxygen, having his breathing medication within immediate reach likely felt like a necessity rather than a rule violation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mcclure Post Acute from 2026-04-09 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 13, 2026 · Our methodology
MCCLURE POST ACUTE in OAKLAND, CA was cited for violations during a health inspection on April 9, 2026.
The breathing medication sat unsecured on Resident 76's tray table at McClure Post Acute when federal inspectors arrived in April.
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.
Frequently Asked Questions
- What happened at MCCLURE POST ACUTE?
- The breathing medication sat unsecured on Resident 76's tray table at McClure Post Acute when federal inspectors arrived in April.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in OAKLAND, CA, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from MCCLURE POST ACUTE or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 555067.
- Has this facility had violations before?
- To check MCCLURE POST ACUTE's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.