River's Bend Health & Rehab Center
800 King Russ Road, Harrisburg, PA 17109 · Dauphin County · 198 certified beds · avg 151 residents/day · certified since Dec 1, 1977
Abuse citation flag (CMS)
Part of chain: SABER HEALTHCARE GROUP (126 facilities, chain avg rating 2.9★)
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: ★☆☆☆☆1/5 · CMS overall rating: 1/5
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 · Jul 1, 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 (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: Jun 16, 2026 (Past Non-Compliance)
▲ Immediate jeopardy, one-off · Jul 8, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
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: Jun 29, 2025 (Past Non-Compliance)
▲ Actual harm, one-off · Mar 12, 2026 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
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: Apr 2, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Mar 12, 2026 · F-0791
The facility did not provide or arrange dental services for its residents. Nursing homes are responsible for making sure residents can get dental care.
Why it matters: Dental problems left untreated cause pain, infection, and trouble eating, which can lead to weight loss.
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: Apr 2, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jan 2, 2024 · 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: Feb 1, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jan 2, 2024 · F-0686 · triggered by a complaint
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 (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 1, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (58)
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 |
|---|---|---|
| Jul 1, 2026 | ▲ J · Immediate jeopardy, 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 9, 2026 | D · Potential for 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 |
| Mar 12, 2026 | ▲ G · Actual 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. |
| Mar 12, 2026 | ▲ G · Actual harm, one-off | The facility did not provide or arrange dental services for its residents. Nursing homes are responsible for making sure residents can get dental care. |
| Mar 12, 2026 | E · Potential for harm, repeated | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. |
| Mar 12, 2026 | 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. |
| Mar 12, 2026 | 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 12, 2026 | E · Potential for harm, repeated | 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. |
| Mar 12, 2026 | E · Potential for harm, repeated | The facility did not help a resident get vision and hearing services — such as eye exams, glasses, hearing tests, or hearing aids. |
| Mar 12, 2026 | 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. |
| Mar 12, 2026 | 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. |
| Mar 12, 2026 | 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. |
| Mar 12, 2026 | D · Potential for harm, one-off | The facility did not honor residents' right to form and take part in resident or family groups, such as a resident council. |
| Mar 12, 2026 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Mar 12, 2026 | D · Potential for harm, one-off | The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). |
| Mar 12, 2026 | 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. |
| Mar 12, 2026 | 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. |
| Mar 12, 2026 | 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. |
| Mar 12, 2026 | 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. |
| Mar 12, 2026 | D · Potential for harm, one-off | 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. |
| Jul 8, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Mar 27, 2025 | E · Potential for harm, repeated | 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. |
| Mar 27, 2025 | E · Potential for harm, repeated | 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. |
| Mar 27, 2025 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Mar 27, 2025 | 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. |
| Mar 27, 2025 | 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. |
| Mar 27, 2025 | D · Potential for harm, one-off | When a resident had a planned discharge, the facility did not make sure the necessary information was communicated to the resident and to the doctors or facility taking over their care. |
| Mar 27, 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. |
| Mar 27, 2025 | 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. |
| Mar 27, 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. |
| Mar 27, 2025 | 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. |
| Mar 27, 2025 | 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. |
| Mar 27, 2025 | 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. |
| Oct 31, 2024 | 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 |
| Oct 8, 2024 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Oct 3, 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. · from a complaint |
| Apr 11, 2024 | E · Potential for harm, repeated | 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. |
| Apr 11, 2024 | E · Potential for harm, repeated | 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. |
| Apr 11, 2024 | 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. |
| Apr 11, 2024 | E · Potential for harm, repeated | 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. |
| Apr 11, 2024 | E · Potential for harm, repeated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Apr 11, 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. |
| Apr 11, 2024 | E · Potential for harm, repeated | The facility did not provide care that took into account residents' past trauma or their cultural backgrounds. Care is supposed to be sensitive to what residents have lived through and where they come from. |
| Apr 11, 2024 | E · Potential for harm, repeated | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. |
| Apr 11, 2024 | D · Potential for harm, one-off | The facility hired someone with an official finding of abuse, neglect, exploitation, or theft against them. Facilities are not allowed to employ people with such findings. |
| Apr 11, 2024 | D · Potential for harm, one-off | When a resident had a planned discharge, the facility did not make sure the necessary information was communicated to the resident and to the doctors or facility taking over their care. |
| Apr 11, 2024 | 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. |
| Apr 11, 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. |
| Apr 11, 2024 | 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. |
| Apr 11, 2024 | D · Potential for harm, one-off | 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 11, 2024 | 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. |
| Jan 2, 2024 | ▲ 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 |
| Jan 2, 2024 | ▲ G · Actual harm, 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. · from a complaint |
| Jan 2, 2024 | E · Potential for harm, repeated | 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. · from a complaint |
| Jan 2, 2024 | E · Potential for harm, repeated | 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. · from a complaint |
| Jan 2, 2024 | D · Potential for harm, one-off | The facility did not keep residents' personal and medical information private and confidential. · from a complaint |
| Jan 2, 2024 | D · Potential for harm, one-off | 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. · from a complaint |
| Aug 21, 2023 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (12 → 18).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 1 | 0 | E |
| 2024 | 24 | 2 | G ▲ |
| 2025 | 13 | 1 | J ▲ |
| 2026 | 20 | 3 | 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)
2 fines totaling $45,331.
| Date | Type | Amount / length |
|---|---|---|
| Jul 1, 2026 | Fine | $25,490 |
| Jan 2, 2024 | Fine | $19,841 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Pennsylvania avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.50 | 3.94 | 3.95 | bottom 42% in Pennsylvania; bottom 37% in the U.S. |
| Registered Nurse hours | 0.46 | 0.80 | 0.69 | bottom 19% in Pennsylvania; bottom 32% in the U.S. |
| Weekend total nurse staffing | 3.16 | 3.58 | 3.50 | bottom 40% in Pennsylvania; bottom 40% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.31 | 0.56 | 0.48 | bottom 25% in Pennsylvania; bottom 35% in the U.S. |
| Total nursing staff turnover (%) | 48.1 | 44.5 | 45.8 | bottom 39% in Pennsylvania; bottom 42% in the U.S. |
| RN turnover (%) | 84.6 | 39.9 | 42.9 | bottom 1% in Pennsylvania; bottom 3% in the U.S. |
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 3.75, RN 0.49, weekend 3.38. 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: 2/5 · long-stay residents: 4/5 · short-stay residents: 1/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Benjamin N. Volpe Family Dynasty Trust (dated December 29, 2020) | Organization | ADP of the SNF | NOT APPLICABLE | 07/01/2023 |
| BNV Dynasty LLC | Organization | ADP of the SNF | NOT APPLICABLE | 07/01/2023 |
| Capital Re Group, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 06/30/2023 |
| Carroll, Michelle | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/25/2024 |
| Carroll, Michelle | Individual | ADP of the SNF | NOT APPLICABLE | 08/25/2024 |
| Citrin Cooperman Advisors LLC | Organization | ADP of the SNF | NOT APPLICABLE | 07/01/2023 |
| Dankenbring, Brooke | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/02/2025 |
| Dankenbring, Brooke | Individual | ADP of the SNF | NOT APPLICABLE | 04/02/2025 |
| Decanted William I. Weisberg Family Dynasty Trust (dated Sept 30, 2020 | Organization | ADP of the SNF | NOT APPLICABLE | 07/01/2023 |
| Nicoluzakis, Gregory | Individual | Corporate Officer | NOT APPLICABLE | 07/01/2023 |
| Nicoluzakis, Gregory | Individual | ADP of the SNF | NOT APPLICABLE | 07/01/2023 |
| RKL LLP | Organization | ADP of the SNF | NOT APPLICABLE | 07/01/2023 |
| Saber Governance LLC | Organization | ADP of the SNF | NOT APPLICABLE | 07/01/2023 |
| Saber Healthcare Group LLC | Organization | ADP of the SNF | NOT APPLICABLE | 07/01/2023 |
| Sahi, Harry | Individual | ADP of the SNF | NOT APPLICABLE | 07/01/2023 |
| SHG Management LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 07/01/2023 |
| SHG Management LLC | Organization | ADP of the SNF | NOT APPLICABLE | 07/01/2023 |
| Volpe, Benjamin | Individual | Corporate Director | NOT APPLICABLE | 07/01/2023 |
| Volpe, Benjamin | Individual | Corporate Officer | NOT APPLICABLE | 07/01/2023 |
| Volpe, Benjamin | Individual | ADP of the SNF | 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.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do residents get dental care here — is there a dentist who visits, and how are appointments arranged?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "How do you explain health changes and treatment options to residents and their families?"
- "Walk me through what happens when a resident or family files a grievance — who responds and how fast?"
- "Who completes resident assessments here, and how do you check them for accuracy?"
- "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 |
|---|---|---|---|---|---|
| Spring Creek Rehabilitation and Nursing Center | 2.4 mi | Harrisburg, PA | ★★☆☆☆ | 2/5 | |
| Amoroso Healthcare and Rehabilitation Woodridge | 3.4 mi | Harrisburg, PA | ★☆☆☆☆ | 1/5 | |
| Capitol Rehabilitation and Healthcare Center | 3.8 mi | Harrisburg, PA | ★★★☆☆ | 3/5 | |
| Homeland Center | 4.1 mi | Harrisburg, PA | ★★★★☆ | 4/5 | |
| Gardens at Camp Hill, the | 5.8 mi | Camp Hill, PA | ★★★☆☆ | 2/5 | |
| Gardens at West Shore, the | 6.0 mi | Camp Hill, PA | ★☆☆☆☆ | 1/5 | abuse |
| Camp Hill Skilled Nursing and Rehabilitation Ctr | 6.1 mi | Camp Hill, PA | ★★☆☆☆ | 2/5 | abuse |
| Oak Hill Center for Rehabilitation and Nursing | 6.7 mi | Middletown, PA | ★★☆☆☆ | 1/5 | |
| Courtyard Gardens Nursing and Rehab Ctr | 6.8 mi | Middletown, PA | ★★★★☆ | 4/5 | |
| Bethany Village Retirement Center | 9.8 mi | Mechanicsburg, PA | ★★★★★ | 4/5 | |
| Vibra Rehabilitation Center | 10.9 mi | Mechanicsburg, PA | ★★★☆☆ | 2/5 | |
| Messiah Lifeways at Messiah Village | 10.9 mi | Mechanicsburg, PA | ★★★★★ | 4/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 395395.