Montereau Inc: Nursing Staff Shortages Found - OK
On October 27, inspectors watched as LPN #2 left an unlocked treatment cart next to the nursing station on the second floor and walked away. The cart contained insulin, lidocaine pain patches, Narcan opioid reversal medication, and antiseptic solutions. Staff behind the nurses' station gradually dispersed, leaving the cart completely unattended by 2:01 p.m.
When LPN #2 returned two minutes later, they told inspectors the key was kept "under the trash bags in the open compartment on the side of the cart" for "easy access." The nurse acknowledged medications were stored on the cart and said the protocol required keeping carts locked, but had "no answer for why the cart was unlocked and unattended."
LPN #2 then walked away again without locking the cart.
Another nurse, LPN #3, eventually locked the cart at 2:14 p.m. and told LPN #2 to "Keep that cart locked."
The next day, inspectors found a second treatment cart unlocked on the first floor. This cart sat around the corner from the nurses' desk with the lock facing away from view. The Director of Nursing walked past the unlocked cart without acknowledging it.
A nursing assistant stopped at the cart to grab gloves and entered a resident's room while the cart remained unlocked.
LPN #1 told inspectors they "forgot to lock the cart" when confronted about the violation.
The Director of Nursing told inspectors that carts should be locked when out of sight and keys should be kept on nursing staff, not stored in open compartments. The facility operates six treatment carts and six medication carts total.
Both violations occurred during regular afternoon hours when residents and visitors move freely through the facility.
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
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
Montereau, Inc. in Tulsa, OK was cited for violations during a health inspection on November 21, 2025.
On October 27, inspectors watched as LPN #2 left an unlocked treatment cart next to the nursing station on the second floor and walked away.
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.