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Montereau Inc.: Pharmacy Service Deficiencies - OK

Healthcare Facility
Montereau, Inc.
Tulsa, OK  ·  4/5 stars

Federal inspectors documented two separate incidents where staff violated basic medication security protocols at the facility.

On the afternoon of October 27, LPN #2 left an unlocked treatment cart next to the second-floor nursing station while talking to a nursing student, then walked away entirely. The cart contained insulin, Narcan, lidocaine pain patches, and antiseptic solutions. For four minutes, the medications sat accessible to anyone walking by.

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When questioned, LPN #2 admitted they kept the cart key "under the trash bags in the open compartment on the side of the cart" for "easy access." They acknowledged medications were stored on the cart but "did not have an answer for why the cart was unlocked and unattended."

The nurse walked away again, leaving the cart unlocked.

Another nurse, LPN #3, eventually locked the cart and told LPN #2 to "Keep that cart locked."

The next day, inspectors found the first-floor North treatment cart unlocked around the corner from the nurses' desk, positioned so its lock faced away from staff view. A nursing assistant stopped to grab gloves from the top while the cart remained unsecured.

LPN #1 admitted they "forgot to lock the cart."

The Director of Nursing told inspectors that carts "should have been locked" when out of sight and that nurses should keep keys "on them." The DON claimed to monitor cart security through rounds, yet walked past the unlocked first-floor cart without acknowledging the violation.

The facility operates six treatment carts and six medication carts total, according to the DON.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Montereau, Inc. from 2025-11-21 including all violations, facility responses, and corrective action plans.

Additional Resources


Editorial Standards

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 20, 2026  ·  Our methodology

Quick Answer

Montereau, Inc. in Tulsa, OK was cited for violations during a health inspection on November 21, 2025.

Federal inspectors documented two separate incidents where staff violated basic medication security protocols at the facility.

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 Montereau, Inc.?
Federal inspectors documented two separate incidents where staff violated basic medication security protocols at the facility.
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 Tulsa, OK, (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 Montereau, Inc. 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 375460.
Has this facility had violations before?
To check Montereau, Inc.'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.


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