Cleveland Care and Rehab Center
900 N Division St, Cleveland, OK 74020 · Pawnee County · 90 certified beds · avg 61 residents/day · certified since Oct 24, 2003
Part of chain: MGM HEALTHCARE (27 facilities, chain avg rating 2.3★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★★☆4/5 · CMS overall rating: 4/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Apr 4, 2025 · F-0624 · triggered by a complaint
The facility did not properly prepare residents for a safe transfer or discharge. Before a resident leaves, the facility must get them ready and make sure the move is safe and orderly.
Why it matters: An unprepared discharge can send a resident somewhere unsafe or without the care arrangements they need.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Mar 7, 2025 (Past Non-Compliance)
All citations in the current public record (31)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Dec 8, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Dec 8, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Dec 8, 2025 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. |
| Dec 8, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Aug 21, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Apr 4, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not properly prepare residents for a safe transfer or discharge. Before a resident leaves, the facility must get them ready and make sure the move is safe and orderly. · from a complaint |
| Apr 4, 2025 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint |
| Mar 19, 2025 | D · Potential for harm, one-off | The facility did not let a resident help develop and carry out their own plan of care — the written roadmap of the services and support they'll receive, built around their personal goals and preferences. · from a complaint |
| Apr 5, 2024 | E · Potential for harm, repeated | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Apr 5, 2024 | E · Potential for harm, repeated | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Apr 5, 2024 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Apr 5, 2024 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Apr 5, 2024 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. |
| Apr 5, 2024 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Apr 5, 2024 | D · Potential for harm, one-off | The facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status. |
| Dec 6, 2023 | E · Potential for harm, repeated | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. · from a complaint |
| Jan 26, 2023 | E · Potential for harm, repeated | The facility did not honor residents' right to manage their own money and financial affairs. |
| Jan 26, 2023 | E · Potential for harm, repeated | The facility did not properly hold, secure, and manage residents' personal money that was deposited with it for safekeeping. Facilities holding residents' funds must keep careful, honest accounts. |
| Jan 26, 2023 | E · Potential for harm, repeated | The facility did not properly protect the personal money residents deposited with it for safekeeping. |
| Jan 26, 2023 | E · Potential for harm, repeated | The facility did not fully assess residents on time — a complete assessment of health, abilities, and needs is required when a resident is first admitted and at least once every 12 months after that. |
| Jan 26, 2023 | E · Potential for harm, repeated | The facility did not enter each resident's assessment information into the required format and send it to the state within 7 days of completing the assessment, as the rules require. |
| Jan 26, 2023 | E · Potential for harm, repeated | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Jan 26, 2023 | E · Potential for harm, repeated | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Jan 26, 2023 | E · Potential for harm, repeated | The facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service. |
| Jan 26, 2023 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jan 26, 2023 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Jan 26, 2023 | D · Potential for harm, one-off | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| Jan 26, 2023 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| Jan 26, 2023 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Jan 26, 2023 | D · Potential for harm, one-off | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Jan 26, 2023 | D · Potential for harm, one-off | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (7 → 4).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 16 | 0 | E |
| 2024 | 7 | 0 | E |
| 2025 | 8 | 1 | J ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $14,069.
| Date | Type | Amount / length |
|---|---|---|
| Mar 19, 2025 | Fine | $14,069 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Oklahoma avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.02 | 4.58 | 3.95 | bottom 19% in Oklahoma; top 38% in the U.S. |
| Registered Nurse hours | 0.40 | 0.41 | 0.69 | top 44% in Oklahoma; bottom 22% in the U.S. |
| Weekend total nurse staffing | 3.65 | 4.16 | 3.50 | bottom 21% in Oklahoma; top 36% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.26 | 0.28 | 0.48 | top 48% in Oklahoma; bottom 23% in the U.S. |
| Total nursing staff turnover (%) | 72.3 | 55.5 | 45.8 | bottom 12% in Oklahoma; bottom 4% in the U.S. |
| RN turnover (%) | 0.0 | 53.6 | 42.9 | — |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.66, RN 0.36, weekend 3.32. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 4/5 · short-stay residents: 3/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| JFB Ok Trust | Organization | 5% or Greater Indirect Ownership Interest | 50% | 01/09/2024 |
| Ok SNF Holdings, LLC | Organization | 5% or Greater Direct Ownership Interest | 50% | 01/09/2024 |
| Ok SNF Investments, LLC | Organization | 5% or Greater Direct Ownership Interest | 50% | 01/09/2024 |
| Southeast Ventures Trust | Organization | 5% or Greater Indirect Ownership Interest | 48% | 01/09/2024 |
| Friedman, Naftali | Individual | Corporate Officer | NOT APPLICABLE | 01/09/2024 |
| Upshaw, Billie | Individual | W-2 Managing Employee | NOT APPLICABLE | 01/09/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What does your discharge planning process look like, and how are families involved before a move?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you decide when a feeding tube is truly needed, and how do staff care for residents who have one?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
- "How are residents and families included in care plan meetings, and how often do those meetings happen?"
- "What is your approach to psychiatric medications — how do you try non-drug options first and work to reduce doses over time?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Cimarron Pointe Care Center | 11.5 mi | Mannford, OK | ★★★★★ | 5/5 | |
| Southern Oaks Care Center | 18.7 mi | Pawnee, OK | ★★★★☆ | 4/5 |
Compare this facility with the 2 closest →
Facility data as of CMS processing date 2026-08-01. CCN 375443.