McClure Post Acute: Staff Untrained on Medications - CA
Federal inspectors found that McClure Post Acute failed to train its nursing staff on monitoring residents who keep medications at their bedside, leaving a patient with acute and chronic respiratory failure to track his own breathing treatments without proper oversight.
The resident told inspectors on April 9 that he kept his albuterol sulfate inhaler in a locked box in his room and used it as needed to help with breathing. He said he last took the medication on April 7 at 7 p.m. and wrote it down on paper.
Staff never asked him to report when he used the inhaler.
When inspectors interviewed Licensed Vocational Nurse 2 about how staff would know when the resident self-administered albuterol, the nurse was unaware of any actions to track the medication use.
Licensed Vocational Nurse 3 said she wasn't sure about the process for self-administered medications kept at bedside.
The Director of Nursing admitted the facility had provided no education or training to nursing staff regarding monitoring and documentation of self-administered medications. She said staff should ask the resident at the end of every shift how many times he used the medication, when he took it, and document that information on his Medication Administration Record.
Nobody was doing that.
The Director of Nursing acknowledged staff weren't monitoring the resident's use of the albuterol inhaler or watching for possible side effects.
Records revealed the gap in oversight. The resident's Medication Administration Record showed no albuterol administration on April 7, despite his statement that he used it that evening. The record indicated the last documented dose was March 22 at 2:47 p.m.
That meant nearly three weeks of undocumented medication use for a resident whose medical chart listed acute and chronic respiratory failure with hypoxia — a condition where the body doesn't get enough oxygen.
The facility had a written policy dating to February 2021 that specifically required nursing staff to review self-administered medication records each shift and transfer information to the official medication record, noting that doses were self-administered.
The policy wasn't being followed.
The resident's face sheet showed diagnoses that made proper medication monitoring critical. Acute respiratory failure means sudden breathing problems that can be life-threatening. Chronic respiratory failure indicates ongoing breathing difficulties. Hypoxia occurs when body tissues don't receive adequate oxygen.
Albuterol sulfate is a bronchodilator that relaxes muscles in the airways to improve breathing. For someone with severe respiratory conditions, knowing when and how often the medication is used helps medical staff assess the patient's condition and adjust treatment.
The inspection found the facility's failure affected monitoring of side effects as well. Albuterol can cause increased heart rate, tremors, and other reactions that require medical oversight, particularly in elderly residents who may have multiple health conditions.
Three different nurses demonstrated the training gap during interviews. Two were uncertain about procedures, and one was completely unaware of monitoring requirements. The systematic lack of knowledge pointed to an institutional failure rather than individual mistakes.
The Director of Nursing's admission that no training had been provided confirmed inspectors' findings. Despite having a written policy for nearly three years, staff responsible for medication safety had never received instruction on implementation.
The violation placed the resident at risk for medication errors and undetected complications. Without documentation, medical staff couldn't determine if breathing treatments were adequate or if the resident needed different interventions.
Federal inspectors classified the deficiency as causing minimal harm or potential for actual harm, affecting few residents. The finding was part of a broader inspection of medication management practices at the 2910 McClure Street facility.
The resident continued managing his breathing medication alone, writing doses on paper while nursing staff remained unaware of his actual medication use.
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 14, 2026 · Our methodology
MCCLURE POST ACUTE in OAKLAND, CA was cited for violations during a health inspection on April 9, 2026.
The resident told inspectors on April 9 that he kept his albuterol sulfate inhaler in a locked box in his room and used it as needed to help with breathing.
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 resident told inspectors on April 9 that he kept his albuterol sulfate inhaler in a locked box in his room and used it as needed to help with breathing.
- 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.