St Joseph Manor Health & Rehabilitation
1317 North 36th Street, Saint Joseph, MO 64506 · Buchanan County · 110 certified beds · avg 64 residents/day · certified since Apr 22, 2003
Abuse citation flag (CMS)
Part of chain: MO OP HOLDCO, LLC (9 facilities, chain avg rating 2.6★)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
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 · Jan 29, 2024 · F-0686
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
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: Feb 16, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jun 25, 2026 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
▲ Actual harm, one-off · May 12, 2026 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: May 14, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Feb 22, 2024 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Feb 23, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jan 29, 2024 · F-0697
The facility did not provide safe and appropriate pain management for a resident who needed it.
Why it matters: Untreated pain causes needless suffering and can lead to depression, poor sleep, and declining health.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Feb 16, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Sep 25, 2023 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Oct 8, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (60)
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 |
|---|---|---|
| Jun 25, 2026 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Jun 25, 2026 | D · Potential for harm, one-off | The facility did not honor residents' right to manage their own money and financial affairs. · from a complaint |
| Jun 25, 2026 | D · Potential for harm, one-off | The facility did not have policies on smoking. · from a complaint |
| May 12, 2026 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Dec 16, 2025 | D · Potential for harm, one-off | The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. · from a complaint |
| Mar 21, 2025 | F · Potential for harm, facility-wide | The facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service. |
| Mar 21, 2025 | F · Potential for harm, facility-wide | 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. |
| Mar 21, 2025 | 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. |
| Mar 21, 2025 | 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. |
| Mar 21, 2025 | D · Potential for harm, one-off | The facility did not provide the social services residents need — such as counseling, help with adjustment, or connecting to outside resources — to achieve the best possible quality of life. |
| Mar 21, 2025 | D · Potential for harm, one-off | The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective. |
| Feb 22, 2024 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Jan 29, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Jan 29, 2024 | ▲ G · Actual harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. |
| Jan 29, 2024 | F · Potential for harm, facility-wide | The facility did not designate a physician to serve as medical director — the doctor responsible for overseeing resident care policies and coordinating medical care across the facility. |
| Jan 29, 2024 | F · Potential for harm, facility-wide | The facility's quality committee — the internal group responsible for finding and fixing care problems — did not have the required members or did not meet at least every three months. |
| Jan 29, 2024 | E · Potential for harm, repeated | The facility did not honor residents' right to form and take part in resident or family groups, such as a resident council. |
| Jan 29, 2024 | E · Potential for harm, repeated | The facility did not give residents the required written notice of their rights, the facility's rules, the services offered, and what those services cost. |
| Jan 29, 2024 | E · Potential for harm, repeated | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. |
| Jan 29, 2024 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Jan 29, 2024 | E · Potential for harm, repeated | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Jan 29, 2024 | E · Potential for harm, repeated | The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. |
| Jan 29, 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. |
| Jan 29, 2024 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Jan 29, 2024 | E · Potential for harm, repeated | The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems. |
| Jan 29, 2024 | E · Potential for harm, repeated | The facility did not serve meals and snacks at times that fit residents' needs, preferences, and requests, or did not offer nourishing alternatives for residents who want to eat outside scheduled meal times. |
| Jan 29, 2024 | E · Potential for harm, repeated | 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. |
| Jan 29, 2024 | E · Potential for harm, repeated | The facility did not arrange hospice services for a resident who needed them, or help the resident move to a facility that could arrange hospice. Hospice provides comfort-focused care for people nearing the end of life. |
| Jan 29, 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. |
| Jan 29, 2024 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Jan 29, 2024 | D · Potential for harm, one-off | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. |
| Jan 29, 2024 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Sep 25, 2023 | ▲ G · Actual 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 |
| Jun 15, 2021 | F · Potential for harm, facility-wide | The facility did not serve meals and snacks at times that fit residents' needs, preferences, and requests, or did not offer nourishing alternatives for residents who want to eat outside scheduled meal times. |
| Jun 15, 2021 | F · Potential for harm, facility-wide | 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. |
| Jun 15, 2021 | E · Potential for harm, repeated | 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. |
| Jun 15, 2021 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Jun 15, 2021 | E · Potential for harm, repeated | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Jun 15, 2021 | E · Potential for harm, repeated | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| Jun 15, 2021 | 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. |
| Jun 15, 2021 | 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. |
| Jun 15, 2021 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Jun 15, 2021 | E · Potential for harm, repeated | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Jun 15, 2021 | E · Potential for harm, repeated | The facility did not regularly inspect bed frames, mattresses, and bed rails for safety, or the rails and mattresses were not attached safely to the frames. |
| Jun 15, 2021 | D · Potential for harm, one-off | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. |
| Jun 15, 2021 | 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. |
| Jun 15, 2021 | D · Potential for harm, one-off | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. |
| Jun 15, 2021 | D · Potential for harm, one-off | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. |
| Jun 15, 2021 | D · Potential for harm, one-off | 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. |
| Jun 15, 2021 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Jun 15, 2021 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Jun 15, 2021 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Jun 15, 2021 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Jun 15, 2021 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Jun 15, 2021 | 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. |
| Jun 15, 2021 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Jun 15, 2021 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Jun 15, 2021 | 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. |
| Jun 15, 2021 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| Jun 15, 2021 | 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. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (20 → 6).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2021 | 27 | 0 | F |
| 2023 | 1 | 1 | G ▲ |
| 2024 | 21 | 3 | J ▲ |
| 2025 | 7 | 0 | F |
| 2026 | 4 | 2 | G ▲ |
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 $10,414.
| Date | Type | Amount / length |
|---|---|---|
| Jan 29, 2024 | Fine | $10,414 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Missouri avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.77 | 3.66 | 3.95 | top 43% in Missouri; bottom 50% in the U.S. |
| Registered Nurse hours | 0.31 | 0.49 | 0.69 | bottom 29% in Missouri; bottom 11% in the U.S. |
| Weekend total nurse staffing | 3.19 | 3.22 | 3.50 | top 48% in Missouri; bottom 41% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.19 | 0.33 | 0.48 | bottom 26% in Missouri; bottom 11% in the U.S. |
| Total nursing staff turnover (%) | 50.8 | 56.0 | 45.8 | top 36% in Missouri; bottom 35% in the U.S. |
| RN turnover (%) | 0.0 | 47.8 | 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 3.50, RN 0.29, weekend 2.96. 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: 3/5 · short-stay residents: 3/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Lichtenstein, Eli | Individual | Indirect Ownership Interest | NOT APPLICABLE | 03/11/2024 |
| Lichtenstein, Isaac | Individual | Indirect Ownership Interest | NOT APPLICABLE | 03/11/2024 |
| Mandelbaum, Chaim | Individual | Indirect Ownership Interest | NOT APPLICABLE | 03/11/2024 |
| Charumuka, Tawanda | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/22/2024 |
| Charumuka, Tawanda | Individual | ADP of the SNF | NOT APPLICABLE | 02/22/2024 |
| Kramer, Shmuel | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2023 |
| Kramer, Shmuel | Individual | ADP of the SNF | NOT APPLICABLE | 07/01/2023 |
| Lichtenstein, Eli | Individual | Managing Control - Governing Body | NOT APPLICABLE | 07/01/2023 |
| Lichtenstein, Eli | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2023 |
| Lichtenstein, Eli | Individual | ADP of the SNF | NOT APPLICABLE | 03/11/2024 |
| Lichtenstein, Isaac | Individual | ADP of the SNF | NOT APPLICABLE | 03/11/2024 |
| Mandelbaum, Chaim | Individual | Managing Control - Governing Body | NOT APPLICABLE | 07/01/2023 |
| Mandelbaum, Chaim | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2023 |
| Mandelbaum, Chaim | Individual | ADP of the SNF | NOT APPLICABLE | 03/11/2024 |
| Miller, Beverly | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2023 |
| Miller, Beverly | Individual | ADP of the SNF | NOT APPLICABLE | 10/03/2025 |
| St Joseph Manor Property Holdings LLC | Organization | 5% or Greater Security Interest | NOT APPLICABLE | 07/01/2023 |
| St Joseph Manor Property Holdings LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 07/01/2023 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "How do you assess and manage residents' pain, especially for those who have trouble communicating?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "How are residents' personal funds handled here, and what records can families review?"
- "What are your smoking rules, and how do you keep residents who smoke — and everyone around them — safe?"
- "What choices do residents have over their daily schedule, like meal times, bathing, and activities?"
- "Do you have a qualified dietician on staff, and how involved are they in each resident's nutrition plan?"
- "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 |
|---|---|---|---|---|---|
| Carriage Square Rehab and Healthcare Center | 1.0 mi | Saint Joseph, MO | ★☆☆☆☆ | 1/5 | |
| Living Community of St Joseph | 1.8 mi | Saint Joseph, MO | ★★★★☆ | 4/5 | |
| Advanced Care of St Joseph | 2.0 mi | Saint Joseph, MO | ★☆☆☆☆ | 2/5 | |
| St Joseph Chateau | 2.3 mi | Saint Joseph, MO | ★★★★☆ | 4/5 | |
| Belleview Care Center | 2.6 mi | Saint Joseph, MO | ★☆☆☆☆ | 2/5 | abuse |
| Wathena Healthcare & Rehabilitation Center | 8.2 mi | Wathena, KS | ★★★☆☆ | 3/5 | |
| Laverna Manor Health & Rehabilitation | 10.6 mi | Savannah, MO | ★★★☆☆ | 2/5 | abuse |
| Abundant Acres Care and Rehab | 11.0 mi | Savannah, MO | ★★☆☆☆ | 2/5 | |
| Gower Convalescent Center, INC | 16.8 mi | Gower, MO | ★★★☆☆ | 3/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 265762.