Inspection Reports for Countryside Assisted Living of Tahlequah
1380 N HERITAGE LANE, TAHLEQUAH, OK, 74464
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
1.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
63% better than Oklahoma average
Oklahoma average: 4.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
37 residents
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 5
Date: Aug 27, 2025
Visit Reason
A complaint survey was conducted due to allegations including failure to have a nurse and administrator on staff, failure to provide care according to physician orders, and failure to prevent a fall during transportation.
Complaint Details
The complaint included allegations that the center failed to have a nurse and administrator on staff, failed to provide care according to physician orders, and failed to prevent a fall during transportation. The investigation was conducted on 08/26/2025-08/27/2025.
Findings
The investigation found deficiencies including failure to ensure a trained health professional completed assessments, failure to submit timely incident reports, failure to implement self-administration medication assessments, and failure to maintain a quarterly quality assurance committee. The facility was clean and residents were observed interacting with staff.
Deficiencies (5)
Failed to ensure a trained health professional completed an assessment for 1 of 3 sampled residents.
Failed to ensure a Preadmission/14-day assessment was signed/coordinated by an RN or physician for 1 of 3 sampled residents.
Failed to ensure a quality assurance committee met on a quarterly basis.
Failed to submit a follow-up report within 5 working days and a final report within 10 business days for 1 of 3 residents sampled for incident reports.
Failed to implement policy for self-administration medication assessment for 1 of 3 sampled residents.
Report Facts
Facility Census: 37
Incident report follow-up timeframe: 5
Incident report final report timeframe: 10
Self-administration medication assessment sample size: 3
Assessment sample size: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tempal Killman | Enforcement Analyst | Signed enforcement letters and correspondence |
| Carlisa Rogers | Administrator | Facility administrator named in report and correspondence |
Inspection Report
Renewal
Capacity: 55
Deficiencies: 0
Date: May 25, 2025
Visit Reason
This document serves as the renewal license issued to B & H ALF Operations Tahlequah, LLC for the operation of an Assisted Living Center named Countryside Assisted Living of Tahlequah.
Findings
The license certifies that the facility is authorized to conduct and maintain an assisted living center with a maximum capacity of 55 beds, effective from May 25, 2025, through May 25, 2028.
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 1
Date: Feb 13, 2025
Visit Reason
A State Licensure survey with a complaint investigation was conducted due to an allegation that the facility failed to provide sufficient supervision to prevent elopement.
Complaint Details
The complaint alleged the facility failed to provide sufficient supervision to prevent elopement. The investigation included observations, interviews, and record reviews related to wandering and elopement seeking behaviors.
Findings
The investigation found deficiencies including failure to ensure hair nets were worn in the kitchen during food preparation. The deficiencies represented the potential for more than minimal harm.
Deficiencies (1)
Failed to ensure hair nets were worn in the kitchen during 1 of 2 kitchen observations.
Report Facts
Facility Census: 31
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carla Gay | Executive Director | Named as Executive Director in multiple documents |
| Tempal Killman | Enforcement Analyst / Administrative Assistant | Signed enforcement and survey correspondence |
Inspection Report
Original Licensing
Capacity: 55
Deficiencies: 0
Date: Nov 21, 2024
Visit Reason
This document certifies the initial licensing of Countryside Assisted Living of Tahlequah as an Assisted Living Center by the Oklahoma State Department of Health.
Findings
The license is issued pursuant to Oklahoma statutes and state board regulations, authorizing the facility to operate with a maximum capacity of 55 beds at the specified location.
Report Facts
Maximum licensed capacity: 55
Inspection Report
Original Licensing
Capacity: 55
Deficiencies: 0
Date: Nov 21, 2024
Visit Reason
This document serves as the initial licensing certification for Countryside Assisted Living of Tahlequah, authorizing the facility to operate as an Assisted Living Center.
Findings
The license certifies that the facility meets the requirements set by the Oklahoma State Department of Health to conduct and maintain an assisted living center with a maximum capacity of 55 beds.
Report Facts
Maximum licensed capacity: 55
Inspection Report
Renewal
Census: 37
Deficiencies: 3
Date: Jun 19, 2024
Visit Reason
A relicensure survey was conducted from June 17, 2024 through June 19, 2024 at Heritage Grove At Tahlequah Assisted Living.
Findings
The facility was found deficient in ensuring resident assessments were coordinated and signed by a registered nurse or physician for several residents, and that assessments contained signatures of resident or representative interviews. Additionally, the facility failed to secure portable oxygen tanks for a resident using portable oxygen.
Deficiencies (3)
Failed to ensure resident assessments were coordinated and signed by a registered nurse or the resident's physician for four of nine sampled residents.
Failed to ensure resident assessments contained a signature of resident or representative interview for four of nine sampled residents.
Failed to secure portable oxygen tanks for one of two residents who used portable oxygen tanks when leaving their room.
Report Facts
Facility Census: 37
Deficiencies cited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carla Gay | Administrator | Named in relation to the facility and plan of correction |
| Lisa Calvin | Enforcement Analyst II | Signed enforcement and acceptance letters |
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 0
Date: Feb 22, 2024
Visit Reason
The complaint investigation was conducted due to allegations that the center failed to maintain hot water for cooking and bathing, failed to provide baths according to schedule, failed to report a system failure of no hot water to the State Agency, and failed to ensure adequate staff to provide care for dependent residents.
Complaint Details
The complaint investigation involved two complaint numbers (#OK00061224 and #OK00062603) with allegations regarding hot water availability and staffing adequacy. The investigation included interviews, observations, and review of records. The complaints were not substantiated as no deficiencies were cited.
Findings
The investigation found that the facility had hot water in resident apartments, kitchen, and bathrooms throughout the investigation. Residents, staff, and family members reported no problems with hot water availability. Staff were observed assisting residents adequately, and residents and family members reported satisfaction with staffing levels and care. No deficiencies were cited.
Report Facts
Facility Census: 38
Sample Residents: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Calvin | Enforcement Analyst II | Author of the complaint investigation report |
| Carla Gay | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 25
Deficiencies: 2
Date: May 12, 2023
Visit Reason
A state licensure survey with a complaint investigation was conducted due to allegations that the facility failed to ensure dependent residents received timely assistance with activities of daily living, adequate staffing, protection of residents' property, and provision of a clean, comfortable environment.
Complaint Details
Complaint investigation #OK00060581 was conducted based on allegations that the facility failed to provide timely assistance with activities of daily living, adequate staffing, protection of residents' property, and a clean environment. The investigation included observations, interviews, and record reviews.
Findings
The investigation found deficiencies including failure to ensure kitchen staff wore hair restraints and beard coverings, and failure to secure the ice machine accessible to residents. Deficient practice was cited related to food storage, preparation, and service.
Deficiencies (2)
Facility failed to ensure kitchen staff wore hair restraints and beard coverings while working to prevent contamination of food and utensils.
Facility failed to ensure the ice machine accessible to residents was locked when not attended by staff.
Report Facts
Residents receiving meals: 25
Investigation dates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carla Gay | Administrator | Named as facility administrator in multiple documents related to the inspection and plan of correction. |
| Lisa Calvin | Enforcement Analyst | Signed enforcement and revisit letters related to the complaint investigation. |
| Gladys Rosann Dosch | RN | Signed the investigative report dated 2023-05-15. |
Inspection Report
Renewal
Capacity: 55
Deficiencies: 0
Date: May 8, 2023
Visit Reason
This document is a license renewal for an assisted living center, certifying the facility to continue operation under state regulations.
Findings
The license renewal certifies that the facility meets the requirements set by the Oklahoma State Department of Health and is authorized to maintain an assisted living center with a maximum capacity of 55 beds.
Report Facts
Maximum licensed beds: 55
Inspection Report
Original Licensing
Capacity: 55
Deficiencies: 0
Date: Mar 31, 2022
Visit Reason
This document is an initial licensing certification for an assisted living center, authorizing the facility to conduct and maintain operations.
Findings
The license certifies that Home Tahlequah Opco, LLC, doing business as Heritage Grove at Tahlequah Assisted Living, meets the requirements to operate an assisted living center with a maximum capacity of 55 beds.
Report Facts
Maximum licensed beds: 55
Inspection Report
Renewal
Capacity: 55
Deficiencies: 0
Date: Feb 24, 2021
Visit Reason
This document is a license renewal for the Assisted Living Center Brookdale Tahlequah Heritage, certifying the facility to conduct and maintain operations.
Findings
The license renewal certifies that the facility meets the provisions of the Oklahoma Statutes and rules adopted by the State Board of Health for the specified premises.
Report Facts
Maximum licensed beds: 55
Inspection Report
Renewal
Census: 31
Deficiencies: 0
Date: Mar 20, 2019
Visit Reason
A re-licensure survey was conducted on March 19 and 20, 2019, to assess compliance for renewal of the assisted living center license.
Findings
No deficiencies were cited during the inspection. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kay Deferman | Long Term Care Enforcement Reviewer | Signed the cover letter reporting the inspection results |
Notice
Capacity: 55
Deficiencies: 0
Date: Mar 15, 2019
Visit Reason
This document serves as a license renewal certification for the assisted living center operated by Emeritus Corporation, DBA Brookdale Tahlequah Heritage.
Findings
The document certifies that the facility is licensed to conduct and maintain an assisted living center with a maximum capacity of 55 beds. No inspection findings or deficiencies are reported.
Report Facts
Maximum licensed beds: 55
Notice
Capacity: 55
Deficiencies: 0
Date: 12 10 2021 LICENSE 110189
Visit Reason
This document serves as a license renewal notice certifying that Tahlequah Seasons Tenant, LLC is licensed to conduct and maintain an Assisted Living Center at the specified location.
Findings
The document certifies the licensing status and maximum bed capacity of the facility but does not include inspection findings or deficiencies.
Report Facts
Maximum licensed beds: 55
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