Montereau Inc: Pressure Ulcer Care Failures - OK
Federal inspectors documented two separate incidents at Montereau on consecutive days in October where staff abandoned secured medication carts without locking them.
On the facility's second floor, LPN #2 left a treatment cart unlocked next to the nursing station while talking to a nursing student, then walked away entirely out of sight. The cart contained insulin, Narcan, lidocaine patches, and topical antiseptics.
The nurse told inspectors the key was kept hidden under trash bags in an open compartment on the side of the cart for "easy access." When asked why the cart was unlocked and unattended, the nurse said they "did not have an answer" but acknowledged medications were stored inside.
The cart remained unlocked and unattended for at least six minutes. Another nurse eventually walked by and locked it, telling the first nurse to "keep that cart locked."
The next day, inspectors found a similar violation on the first floor. A treatment cart sat unlocked around the corner from the nurses' desk, with the lock facing away from staff view. A nursing assistant stopped to grab gloves from the top while the cart remained unsecured.
LPN #1 told inspectors they "forgot to lock the cart" when confronted about the violation.
The Director of Nursing acknowledged carts should be locked whenever out of sight and that keys should be kept on staff members, not hidden in compartments. The administrator said they monitored cart security through facility rounds.
The DON walked directly past the unlocked first-floor cart without acknowledging the security breach, according to inspection records.
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: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 9, 2026 · Our methodology
Montereau, Inc. in Tulsa, OK was cited for violations during a health inspection on November 21, 2025.
The cart contained insulin, Narcan, lidocaine patches, and topical antiseptics.
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.