Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Montereau, Inc. during CMS and state inspections, most recent first.
A resident who required significant assistance with daily activities and was at risk for falls experienced multiple prolonged waits for call light responses, including one instance where the call light was active for over three hours. The resident, who was cognitively intact and had several medical conditions, reported having to call out for help and being left unattended on the toilet, leading them to slide to the floor. Staff interviews revealed inconsistent expectations and practices regarding call light response times, with some staff acknowledging delays during busy periods and issues with accurately recording response times.
Surveyors found that two treatment carts containing medications and biologicals were left unlocked and unattended in the facility. Staff admitted to leaving keys in accessible locations and not following protocol to keep carts locked when out of sight. The DON confirmed that facility policy requires carts to be locked and keys to be kept on the nurse.
A resident with a history of heart failure and recurrent nosebleeds was discharged from the hospital with instructions to follow up with an ENT physician, but the facility failed to schedule the required appointment. The ADON, responsible for scheduling, did not identify the need for the ENT referral, and there was no documentation or monitoring process in place to ensure the appointment was made. The resident confirmed they were not notified of or sent to the ENT appointment during their stay.
A resident with severe cognitive impairment and a stage three pressure ulcer did not consistently receive a physician-ordered liquid protein supplement, with eight missed doses documented due to issues such as unavailability and lack of staff awareness. Staff interviews revealed confusion about ordering and administration responsibilities, resulting in the resident not receiving the prescribed nutritional support for wound healing.
A resident with heart failure, hypertension, and renal insufficiency did not receive Lasix at the physician-ordered times on multiple occasions. Audit reports showed several doses were administered late, and staff interviews revealed inconsistent adherence to the facility's medication timing protocol. The facility did not ensure medications were given as ordered, resulting in a deficiency related to timely medication administration.
A resident with a history of skin breakdown and high risk for pressure ulcers was admitted with moisture associated skin damage, but the facility failed to accurately assess, document, and care plan for the condition. There was a lack of timely wound care interventions, inconsistent documentation, and poor communication among staff, leading to the progression of a sacral wound to a stage IV pressure ulcer with severe infection and sepsis, ultimately resulting in the resident's death.
The facility failed to ensure enhanced barrier precautions were used during catheter care for two residents with indwelling urinary catheters. Despite the presence of PPE and signage, CNAs did not use gowns as required. Both CNAs admitted to not using gowns, and the DON and infection preventionist confirmed staff had been educated on PPE use.
A resident with dementia and dysphagia had their dietary needs publicly displayed on sheets of paper near the nurses' station, compromising their dignity. RN #1 acknowledged that this information should not be visible to the public and stated that staff could access dietary needs through the care plan and lunch tickets.
The facility failed to ensure residents were offered the choice to formulate an advance directive, as evidenced by the lack of documentation for three residents. One resident with dementia and dysphagia had no advance directive acknowledgment, another with Alzheimer's and sepsis had incomplete social service assessment, and a third resident's advance directive form was only signed on the day of the survey. The Social Services Director confirmed the absence of a form to document advance directives upon admission.
The facility failed to develop comprehensive care plans for four residents, including those with multiple sclerosis, hypertension, and Alzheimer's disease. The MDS assessments were completed, but the care plans were not fully developed as required. Additionally, a resident with Alzheimer's was not weighed as per their care plan, missing 31 out of 37 opportunities.
A resident with cognitive communication deficit and other conditions was abused by a CNA, who was witnessed and videotaped yelling and kicking the resident. The incident was not reported immediately due to the witnessing CNA's fear, violating the facility's abuse policy.
Failure to Provide Timely Call Light Response Due to Insufficient Staffing
Penalty
Summary
The facility failed to provide sufficient staff to answer call lights in a timely manner for one of three sampled residents reviewed for call light response. Call light logs revealed multiple instances where the resident's call light remained active for extended periods, including durations of over an hour and, in one case, more than three hours. Documentation showed that the resident had to call out for help and was found on the bathroom floor after attempting to get assistance for an extended period. The resident reported having to wait 15 to 45 minutes on several occasions for staff to respond to their call light, sometimes resorting to calling the security desk for help at night. The resident involved was cognitively intact, with a BIMS score of 15, and had diagnoses including heart failure, hypertension, and renal insufficiency. The resident required substantial to maximum assistance with activities of daily living, including transfers and toileting, and was considered a fall risk. Despite these needs, the resident reported being left unattended on the toilet for at least 30 minutes, leading them to slide to the floor and crawl toward the door to seek help. Staff interviews confirmed that call light response times varied, with some staff indicating that response times could be longer during busy periods such as mealtimes. Interviews with facility staff, including the DON, LPNs, and CNAs, revealed inconsistencies in the expected and actual response times to call lights. While some staff stated that the expected response time was two minutes, others considered up to 15 minutes to be timely, especially during busy periods. The DON acknowledged that call light response times were monitored only randomly or in response to complaints and that there were issues with staff acknowledging but not turning off call lights, which could affect the accuracy of response time records.
Failure to Secure Medications in Unattended Treatment Carts
Penalty
Summary
Surveyors observed that the facility failed to ensure medications and biologicals were secured in accordance with professional standards. On two separate occasions, treatment carts containing medications such as insulin, Narcan, lidocaine patches, and various antiseptics were found unlocked and unattended. On the second floor, a treatment cart was left unlocked next to the nurses' station while staff were present but not attending to the cart. The key to the cart was found in an open compartment, and staff admitted to leaving it there for easy access, contrary to facility protocol. The cart remained unlocked and unattended for several minutes, with staff unable to provide a reason for this lapse. A similar incident occurred on the first floor, where another treatment cart was observed unlocked and unattended around the corner from the nurses' desk. Staff walked past the cart without securing it, and a CNA accessed supplies from the cart. When questioned, staff acknowledged that the cart should not have been left unlocked and stated it was an oversight. The Director of Nursing confirmed that facility policy required carts to be locked when out of sight and that keys should be kept on the nurse, not left in or near the cart.
Failure to Schedule Required ENT Follow-Up Appointment
Penalty
Summary
A deficiency occurred when the facility failed to schedule a follow-up appointment with an ENT physician for a resident who had been evaluated in the emergency room for a recurrent nosebleed. The resident, who was cognitively intact and had a diagnosis of heart failure, was discharged from the hospital with instructions to follow up with an ENT within five to seven days. Upon return to the facility, there was no documentation in the clinical record or appointment log indicating that the required ENT appointment had been scheduled. Interviews with facility staff revealed that the ADON was responsible for scheduling resident appointments and reviewing hospital records for necessary referrals. The ADON confirmed that, at the time of the resident's readmission, they did not identify the need for an ENT follow-up. The DON stated that there was no known monitoring process in place to ensure that appointments and referrals were scheduled, and could not explain why the ENT appointment was missed. The resident reported not being notified of or attending an ENT appointment during their stay.
Failure to Administer Ordered Nutritional Supplement for Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that nutritional supplements ordered for the treatment of a pressure ulcer were consistently administered to a resident with severe cognitive impairment and multiple medical diagnoses, including coronary artery disease, hypertension, and Alzheimer's disease. The resident was assessed as having increased protein needs due to a stage three pressure ulcer, and a physician's order was in place for liquid protein to be given twice daily. However, review of medication administration records revealed that the supplement was not given on eight occasions out of thirty opportunities, with several missed doses lacking documented reasons or being attributed to the supplement not being available or on order from the pharmacy. Interviews with nursing staff indicated confusion regarding the ordering and administration process for the supplement, with one LPN stating that medications were ordered electronically and should be administered upon arrival, and the ADON noting that the supplement should have been available as house stock. Despite these protocols, the supplement was not administered as ordered, and staff were unable to provide consistent explanations for the missed doses, indicating a breakdown in ensuring the resident received the prescribed nutritional intervention for pressure ulcer care.
Failure to Administer Medications at Ordered Times
Penalty
Summary
The facility failed to ensure that medications were administered at the ordered times for one of three sampled residents reviewed for medication administration. According to the facility's policy, medications are to be administered by licensed nurses or other authorized staff as ordered by the physician, following the six rights of medication administration, including the right time. For a resident with diagnoses of heart failure, hypertension, and renal insufficiency, physician orders specified that Lasix was to be administered twice daily at 7:00 a.m. and 2:00 p.m. However, medication administration audit reports showed multiple instances where Lasix was not given at the ordered time, with doses being administered significantly later than scheduled on several dates. Interviews with staff revealed inconsistencies in following the facility's protocol regarding medication timing. An LPN stated that there was a one-hour window before and after the ordered time for administration, but acknowledged that some doses were given outside this window and could not explain the delays. The DON confirmed the protocol and stated that nurses should report late administrations, but there was no indication that this occurred. The documentation and staff interviews demonstrate that the facility did not consistently adhere to its own medication administration policies, resulting in late administration of prescribed medications.
Failure to Assess, Monitor, and Intervene for Pressure Ulcer Risk and Treatment
Penalty
Summary
A deficiency was identified when the facility failed to properly assess, monitor, and intervene for a resident with a history of skin breakdown and at high risk for pressure ulcers. Upon admission, the resident was documented as having moisture associated skin damage to the right gluteus, but there was no documentation of a deep tissue injury or other wounds. Despite this, there was a lack of accurate and timely documentation regarding the resident's skin condition, and the baseline care plan did not address any skin issues or concerns. The facility also failed to initiate appropriate treatment orders for the skin damage present on admission, and there was no evidence of wound care interventions until a pressure ulcer was later identified. Throughout the resident's stay, multiple nursing notes, skin checks, and care plan reviews continued to document the presence of moisture associated skin damage, but did not identify or address the development of a pressure ulcer. The Braden scale assessments initially indicated a low risk for pressure ulcers, and there was inconsistency in the documentation of the resident's skin status. The care plan eventually noted the resident was at risk for skin breakdown due to incontinence, but did not specifically address the presence or treatment of a pressure ulcer. Weekly wound tracking and physician notes later documented the progression of a sacral wound from suspected deep tissue injury to a stage IV pressure ulcer, with significant necrotic tissue and exudate, and additional wounds on the right heel and left foot. Communication failures were evident, as changes in the resident's skin condition were not consistently reported to the care team or reflected in the care plan. There was a delay in obtaining and following physician orders for wound care, and discrepancies existed between the frequency of ordered dressing changes and what was scheduled in the electronic medical record. The lack of timely and coordinated interventions contributed to the deterioration of the resident's skin condition, ultimately resulting in severe infection, sepsis, and death due to complications from an infected sacral decubitus ulcer.
Failure to Utilize Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
The facility failed to ensure that enhanced barrier precautions were utilized during indwelling urinary catheter care for two residents. Both residents had diagnoses of obstructive and reflux uropathy and were on enhanced barrier precautions due to the presence of indwelling urinary catheters. Despite the presence of personal protective equipment (PPE) bins and signage indicating enhanced barrier precautions outside the residents' doors, the certified nursing assistants (CNAs) providing care did not use gowns as required. CNA #1 and CNA #2 both acknowledged that they were supposed to use gowns and gloves during catheter care but admitted to not doing so during their respective observations. The Director of Nursing (DON) and the infection preventionist confirmed that staff had been educated on the use of PPE for residents on enhanced barrier precautions, yet the CNAs failed to adhere to these protocols during the observed care activities.
Resident Dignity Compromised by Public Display of Dietary Information
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect, as observed in the case of a resident with dementia and dysphagia. The resident was admitted with a physician's order for a regular pureed texture diet with nectar thick consistency liquids. During an observation, the resident was seen sitting near the nurses' station with two 8 x 10 sheets of paper displaying their dietary requirements, including their name and the need for nectar thick liquids. These signs were visible to the public, which was acknowledged by RN #1 as inappropriate, stating that such information should not be publicly displayed. RN #1 also mentioned that staff could access the resident's dietary needs through the care plan and lunch tickets available during meal times.
Failure to Offer Advance Directive Choices
Penalty
Summary
The facility failed to ensure that residents were offered the choice to formulate an advance directive, as evidenced by the lack of documentation for three residents. Resident #7, who was admitted with dementia and dysphagia, had a physician's order and care plan indicating full code status, but there was no advance directive acknowledgment or social services assessment documenting the resident's choice. Similarly, Resident #40, admitted with Alzheimer's and sepsis, had a care plan indicating DNR status, yet the social service assessment lacked information regarding the resident's choice to accept or decline an advance directive. Resident #208's case further highlights the deficiency, as their social service history and initial assessment did not contain any information regarding advance directives. During an interview, the Social Services Director admitted that there was no form to document whether a resident had advance directives upon admission. It was revealed that the forms provided to the survey team were newly created on the day of the survey, and Resident #208's form was signed on the same day, despite the resident being admitted earlier.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans for four residents, as required by their policy. Resident #50, diagnosed with cellulitis of the abdominal wall and multiple sclerosis, did not have a comprehensive care plan completed after the admission MDS assessment was finalized on May 18, 2024. Similarly, Resident #41, with diagnoses including hypertension, a fracture of the left femur, and a transient ischemic attack, also lacked a comprehensive care plan following the completion of their admission MDS assessment on April 25, 2024. In both cases, the MDS Coordinator confirmed that the care plans were not fully completed. Resident #111, who had cerebral infarction, congestive heart failure, and heart failure, was admitted without a comprehensive care plan after their MDS assessment was completed on June 17, 2024. Additionally, Resident #40, diagnosed with Alzheimer's disease and morbid obesity, had a care plan that required weekly weight monitoring due to malnutrition risk. However, the facility failed to obtain the resident's weight on 31 out of 37 opportunities. The MDS Coordinator acknowledged that Resident #40 was not being weighed according to their care plan.
Failure to Immediately Report Abuse
Penalty
Summary
The facility failed to implement their abuse policy by not immediately reporting an incident of abuse. A resident with diagnoses including cognitive communication deficit, displaced intertrochanteric fracture, and depression was subjected to abuse when a CNA was witnessed and videotaped yelling and kicking the resident. The incident occurred at approximately 5:30 a.m. and was not reported to the administrator until 2:30 p.m. the same day. The delay in reporting was due to the witnessing CNA's fear of the abusive CNA. The facility's policy requires immediate reporting of abuse, which was not followed in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Tulsa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tulsa Center For Rehabilitation And Healthcare | 0.7 mi | ★★★★★ | 5 | 0 |
| The Cottage Extended Care | 1.6 mi | ★★★★★ | 0 | 0 |
| Southern Hills Rehabilitation Center | 1.7 mi | ★★★★★ | 0 | 0 |
| The Villages At Southern Hills | 2.8 mi | ★★★★★ | 0 | 0 |
| University Village Retirement Community | 3.2 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.