Editorial Independence

StarlynnCare receives no referral commissions, lead fees, or paid placement from any operator. Rankings are derived solely from state inspection records and verified family reviews.

StarlynnCare
Oregon · Oregon City

River Terrace Memory Care.

River Terrace Memory Care is Grade C−, ranked in the bottom 42% of Oregon memory care with 33 OR DHS citations on record; last inspected Oct 2023.

ALF · Memory Care54 licensed beds · largeDementia-trained staff
950 South End Rd · Oregon City, OR 97045LIC# 0000050472
Facility · Oregon City
River Terrace Memory Care
© Google Street Viewoperator? submit a photo →
A 54-bed ALF · Memory Care with 33 citations on file — most recent Aug 2025.
Last inspection · Oct 2023 · citedSource · OR-DHS
Licensed beds
54
Memory care
✓ Yes
Last inspection
Oct 2023
Last citation
Aug 2025
Operated by
Phone
§ 01 · Snapshot

A large home, reviewed on public record.

§ 02 · Peer Comparison

Ranked against 118 Oregon facilities.

ALF memory care · 36-month window. Higher percentile = better. Source: Oregon Dept. of Human Services · Long-Term Care Licensing.

Severity rank
21th
Weighted citations per bed.
peer median
0
100
Repeat rank
100th
Repeat deficiencies as share of total.
peer median
0
100
Frequency rank
4th
Deficiencies per inspection.
peer median
0
100

FACILITY WATCH · BETA

River Terrace Memory Care has 33 citations on record. Know the moment anything changes.

New findings, complaint investigations, or status changes — emailed to you free.

§ 03 · The Record

Citation history, plotted month by month.

33 deficiencies on record. Each bar is a month with a citation.

89weighted score · 24 mo
Last citation: AUG 2025. Compared against peer median (dashed).
peer median
AUG 2025
Jun 2024May 2026

Finding distribution

33 total · 36 months

Scope × Severity (CMS A–L)

Isolated
Pattern
Widespread
Sev 4 · IJ
J
K
L
Sev 3
G16
H
I
Sev 2
D
E
F
Sev 1
A17
B
C
2025-08-26
Complaint Investigation
OR-DHS
1 · Abuse: Neglect
2025-08-24
Complaint Investigation
OR-DHS
1 · Licensing Violation
2025-03-27
Complaint Investigation
OR-DHS
1 · Abuse: Neglect
2025-02-21
Complaint Investigation
OR-DHS
1 · Licensing Violation
2025-02-16
Complaint Investigation
OR-DHS
1 · Licensing Violation
2025-02-07
Complaint Investigation
OR-DHS
1 · Abuse: Neglect
2025-01-08
Complaint Investigation
OR-DHS
1 · Licensing Violation
2025-01-07
Complaint Investigation
OR-DHS
1 · Licensing Violation
2024-12-28
Complaint Investigation
OR-DHS
1 · Abuse: Neglect
2024-12-20
Complaint Investigation
OR-DHS
1 · Abuse: Neglect
2024-12-07
Complaint Investigation
OR-DHS
1 · Abuse: Neglect
2024-11-03
Complaint Investigation
OR-DHS
1 · Abuse: Neglect
2024-09-07
Complaint Investigation
OR-DHS
1 · Licensing Violation
2024-08-10
Complaint Investigation
OR-DHS
1 · Licensing Violation
2024-07-16
Complaint Investigation
OR-DHS
No findings
2024-07-15
Complaint Investigation
OR-DHS
1 · Abuse: Neglect
2024-06-21
Complaint Investigation
OR-DHS
1 · Licensing Violation
2024-06-03
Complaint Investigation
OR-DHS
1 · Licensing Violation
2024-05-20
Complaint Investigation
OR-DHS
1 · Licensing Violation
2024-05-19
Complaint Investigation
OR-DHS
1 · Licensing Violation
2024-04-24
Complaint Investigation
OR-DHS
1 · Licensing Violation
2024-03-26
Complaint Investigation
OR-DHS
1 · Abuse: Neglect
2024-03-14
Complaint Investigation
OR-DHS
1 · Licensing Violation
2024-03-02
Complaint Investigation
OR-DHS
1 · Abuse: Neglect
2024-01-27
Complaint Investigation
OR-DHS
1 · Abuse: Neglect
2024-01-22
Complaint Investigation
OR-DHS
1 · Abuse: Neglect
2024-01-11
Complaint Investigation
OR-DHS
1 · Abuse: Neglect
2024-01-09
Complaint Investigation
OR-DHS
1 · Licensing Violation
2024-01-01
Complaint Investigation
OR-DHS
1 · Abuse: Neglect
2023-12-31
Complaint Investigation
OR-DHS
1 · Licensing Violation
2023-12-18
Complaint Investigation
OR-DHS
No findings
2023-12-01
Complaint Investigation
OR-DHS
1 · Licensing Violation
2023-11-29
Complaint Investigation
OR-DHS
1 · Abuse: Neglect
2023-10-24
Annual Compliance Visit
OR-DHS
No findings
2023-10-11
Annual Compliance Visit
OR-DHS
No findings
2023-08-21
Complaint Investigation
OR-DHS
1 · Abuse: Neglect
2023-08-07
Complaint Investigation
OR-DHS
1 · Licensing Violation
§ 05 · Tour Prep

Questions to ask before you visit.

A short pre-tour checklist tailored to River Terrace Memory Care's record and state requirements.

01 /

The facility holds an Oregon DHS Memory Care Endorsement and has 49 inspection reports on file — can you walk us through the written dementia care program that supports the endorsement, and explain how staff competency in dementia care is documented and verified?

Ask the operator on tour. Take notes and compare answers across facilities you visit.

02 /

Records show 46 complaints filed with Oregon DHS Long-Term Care Licensing — were any of those complaints substantiated, and can you share the facility's own corrective action plans or incident reports that document how substantiated findings were addressed?

Ask the operator on tour. Take notes and compare answers across facilities you visit.

03 /

With 43 deficiencies cited across the inspection history, what systems are in place to track compliance gaps before they appear in state reports, and can you show us documentation of internal audits or quality improvement meetings?

Ask the operator on tour. Take notes and compare answers across facilities you visit.

§ 06 · Full Inspection Record

Every OR-DHS visit, verbatim.

37 inspections in the public record, most recent first. Click any row to expand — cited rows open automatically.

37
reports on file
33
total deficiencies
2025-08-26
Complaint Investigation
1 · Abuse: Neglect

Plain-language summary

A complaint was investigated alleging that the facility failed to provide a service. The investigation did not substantiate the complaint.

Abuse: NeglectOAR §__or_82c01d155d65b3457c226806d2a8fe0e
Verbatim citation text · OAR §__or_82c01d155d65b3457c226806d2a8fe0e

Failed to provide service

Full inspector notes

—: Failed to provide service

2025-08-24
Complaint Investigation
1 · Licensing Violation

Plain-language summary

A complaint was investigated alleging that a facility failed to administer medication as ordered. The investigation found a licensing violation related to medication administration. The facility was required to take corrective action to ensure medications are given according to the prescribing physician's instructions.

Licensing ViolationOAR §__or_3af74815ebea487ff938270d4a7cf53e
Verbatim citation text · OAR §__or_3af74815ebea487ff938270d4a7cf53e

Failed to administer medication as ordered

Full inspector notes

—: Failed to administer medication as ordered

2025-03-27
Complaint Investigation
1 · Abuse: Neglect

Plain-language summary

A complaint was investigated regarding failure to administer medication as ordered. The investigation outcome has not yet been determined or is not available in this report.

Abuse: NeglectOAR §__or_12a43dea6e1ee8da0ffe08d110934832
Verbatim citation text · OAR §__or_12a43dea6e1ee8da0ffe08d110934832

Failed to administer medication as ordered

Full inspector notes

—: Failed to administer medication as ordered

2025-02-21
Complaint Investigation
1 · Licensing Violation

Plain-language summary

A complaint was investigated regarding failure to provide a safe medication administration system. The investigation found a licensing violation in medication administration practices at the facility.

Licensing ViolationOAR §__or_ca389bf4b1d48955efa54ffbac479d09
Verbatim citation text · OAR §__or_ca389bf4b1d48955efa54ffbac479d09

Failed to provide a safe medication administration system

Full inspector notes

—: Failed to provide a safe medication administration system

2025-02-16
Complaint Investigation
1 · Licensing Violation

Plain-language summary

A complaint was investigated alleging that medication was not administered as ordered. The investigation found a licensing violation related to medication administration. The facility failed to follow the prescribed medication regimen for a resident.

Licensing ViolationOAR §__or_f07d73dc5436da7780bae94bf527e58e
Verbatim citation text · OAR §__or_f07d73dc5436da7780bae94bf527e58e

Failed to administer medication as ordered

Full inspector notes

—: Failed to administer medication as ordered

2025-02-07
Complaint Investigation
1 · Abuse: Neglect

Plain-language summary

A complaint investigation found that the facility failed to provide a safe medication administration system. No further details about the specific deficiency or corrective actions are provided in the available information.

Abuse: NeglectOAR §__or_d34466dcc452e92da49edb6ca93cb104
Verbatim citation text · OAR §__or_d34466dcc452e92da49edb6ca93cb104

Failed to provide a safe medication administration system

Full inspector notes

—: Failed to provide a safe medication administration system

2025-01-08
Complaint Investigation
1 · Licensing Violation

Plain-language summary

A complaint was received that a facility failed to administer medication as ordered. The investigation outcome was not specified in the available documentation. Families should contact the facility or Oregon DHS directly for the final determination and any corrective actions taken.

Licensing ViolationOAR §__or_e13bd1728fe6563e4ab9ea224fdbafe9
Verbatim citation text · OAR §__or_e13bd1728fe6563e4ab9ea224fdbafe9

Failed to administer medication as ordered

Full inspector notes

—: Failed to administer medication as ordered

2025-01-07
Complaint Investigation
1 · Licensing Violation

Plain-language summary

A complaint investigation found that the facility failed to provide a safe medication administration system. The specific deficiencies and corrective actions required were not detailed in the available inspection documentation.

Licensing ViolationOAR §__or_9f75ec1b986436fb53dbc99828902e9c
Verbatim citation text · OAR §__or_9f75ec1b986436fb53dbc99828902e9c

Failed to provide a safe medication administration system

Full inspector notes

—: Failed to provide a safe medication administration system

2024-12-28
Complaint Investigation
1 · Abuse: Neglect

Plain-language summary

A complaint was investigated alleging that the facility failed to provide a required service. The investigation did not substantiate the complaint, and no licensing violation was found.

Abuse: NeglectOAR §__or_dfaeb83afccc01e814c4fdb7b446b255
Verbatim citation text · OAR §__or_dfaeb83afccc01e814c4fdb7b446b255

Failed to provide service

Full inspector notes

—: Failed to provide service

2024-12-20
Complaint Investigation
1 · Abuse: Neglect

Plain-language summary

A complaint was investigated regarding failure to provide a safe environment. The narrative provided does not contain sufficient detail about what specific unsafe conditions were found or what the outcome of the investigation was. To learn more about this complaint, you may contact Oregon DHS Long-Term Care Licensing directly for the full inspection report.

Abuse: NeglectOAR §__or_e5e3116d010b2094deec7d1b9815783c
Verbatim citation text · OAR §__or_e5e3116d010b2094deec7d1b9815783c

Failed to provide safe environment

Full inspector notes

—: Failed to provide safe environment

2024-12-07
Complaint Investigation
1 · Abuse: Neglect

Plain-language summary

A complaint was investigated regarding failure to provide service at this facility. The investigation outcome was not documented in the available record, so it cannot be determined whether the complaint was substantiated or what corrective action, if any, was required.

Abuse: NeglectOAR §__or_d1ba3d25b200b944f057ca0091b0808d
Verbatim citation text · OAR §__or_d1ba3d25b200b944f057ca0091b0808d

Failed to provide service

Full inspector notes

—: Failed to provide service

2024-11-03
Complaint Investigation
1 · Abuse: Neglect

Plain-language summary

A complaint investigation found that the facility failed to provide a service to a resident. The specific service that was not provided and details of the outcome are not included in the available information.

Abuse: NeglectOAR §__or_074690cef6cb1667bb02ecb4fe17db20
Verbatim citation text · OAR §__or_074690cef6cb1667bb02ecb4fe17db20

Failed to provide service

Full inspector notes

—: Failed to provide service

2024-09-07
Complaint Investigation
1 · Licensing Violation

Plain-language summary

A complaint was investigated regarding failure to follow a resident's care plan. The investigation found that the facility did not implement the care plan as written. No further outcome information was provided in the inspection record.

Licensing ViolationOAR §__or_529b5f5c90fdbb15dc059af32b83419b
Verbatim citation text · OAR §__or_529b5f5c90fdbb15dc059af32b83419b

Failed to follow care plan

Full inspector notes

—: Failed to follow care plan

2024-08-10
Complaint Investigation
1 · Licensing Violation

Plain-language summary

A complaint was investigated that the facility failed to follow a resident's care plan. The investigation found a licensing violation for failure to implement the care plan as written. The facility was required to correct this violation.

Licensing ViolationOAR §__or_d67d163489b7896c6c23df097da251f2
Verbatim citation text · OAR §__or_d67d163489b7896c6c23df097da251f2

Failed to follow care plan

Full inspector notes

—: Failed to follow care plan

2024-07-16
Complaint Investigation
No findings
2024-07-15
Complaint Investigation
1 · Abuse: Neglect

Plain-language summary

A complaint was investigated alleging the facility failed to provide a service. The investigation did not substantiate this complaint, and no violation was found.

Abuse: NeglectOAR §__or_d746c01a6b882fec94e70cbb4f023058
Verbatim citation text · OAR §__or_d746c01a6b882fec94e70cbb4f023058

Failed to provide service

Full inspector notes

—: Failed to provide service

2024-06-21
Complaint Investigation
1 · Licensing Violation

Plain-language summary

A complaint was investigated regarding failure to provide or assist with hygiene. The investigation outcome was not substantiated, meaning no violation was found.

Licensing ViolationOAR §__or_a797dabc1f3fd69c4d359a04eb62f5f7
Verbatim citation text · OAR §__or_a797dabc1f3fd69c4d359a04eb62f5f7

Failed to provide or assist with hygiene

Full inspector notes

—: Failed to provide or assist with hygiene

2024-06-03
Complaint Investigation
1 · Licensing Violation

Plain-language summary

A complaint was investigated regarding failure to use an ABST (Assault/Behavior Support Team or similar de-escalation protocol). The investigation did not result in a substantiated violation, meaning the allegation was not confirmed.

Licensing ViolationOAR §__or_e73b3cf0aa3e06623cb7a797622fdf51
Verbatim citation text · OAR §__or_e73b3cf0aa3e06623cb7a797622fdf51

Failed to use an ABST

Full inspector notes

—: Failed to use an ABST

2024-05-20
Complaint Investigation
1 · Licensing Violation

Plain-language summary

A complaint was investigated that the facility failed to follow a resident's care plan. The investigation outcome has not yet been determined or is pending finalization.

Licensing ViolationOAR §__or_9f10b9f0966b175ce8f7484866f807dd
Verbatim citation text · OAR §__or_9f10b9f0966b175ce8f7484866f807dd

Failed to follow care plan

Full inspector notes

—: Failed to follow care plan

2024-05-19
Complaint Investigation
1 · Licensing Violation

Plain-language summary

A complaint was investigated that the facility failed to provide a safe environment. The investigation outcome was not specified in the available information. Families should contact Oregon DHS Long-Term Care Licensing directly for the complete investigation findings.

Licensing ViolationOAR §__or_df82608f6bddff0cf2b17f33d85b8afc
Verbatim citation text · OAR §__or_df82608f6bddff0cf2b17f33d85b8afc

Failed to provide safe environment

Full inspector notes

—: Failed to provide safe environment

2024-04-24
Complaint Investigation
1 · Licensing Violation

Plain-language summary

A complaint investigation found that the facility failed to use an anti-bullying and safety team (ABST) as required by Oregon licensing rules. The facility did not have this required team in place to address bullying and safety concerns.

Licensing ViolationOAR §__or_320694a87979033c81751b67b62050ae
Verbatim citation text · OAR §__or_320694a87979033c81751b67b62050ae

Failed to use an ABST

Full inspector notes

—: Failed to use an ABST

2024-03-26
Complaint Investigation
1 · Abuse: Neglect

Plain-language summary

A complaint was investigated that the facility failed to provide a safe environment. The outcome of that investigation was not yet determined or reported. Families should contact Oregon DHS Long-Term Care Licensing for the final disposition of this complaint.

Abuse: NeglectOAR §__or_a6660cf8256ed1ed2a741d50e8f138f1
Verbatim citation text · OAR §__or_a6660cf8256ed1ed2a741d50e8f138f1

Failed to provide safe environment

Full inspector notes

—: Failed to provide safe environment

2024-03-14
Complaint Investigation
1 · Licensing Violation

Plain-language summary

A complaint investigation found that the facility failed to use an approved behavior support tool (ABST) as required by licensing rules. No further details about the circumstances or resolution are provided in this summary.

Licensing ViolationOAR §__or_3df27c4d6061156bf8ccdfb6cfc281d2
Verbatim citation text · OAR §__or_3df27c4d6061156bf8ccdfb6cfc281d2

Failed to use an ABST

Full inspector notes

—: Failed to use an ABST

2024-03-02
Complaint Investigation
1 · Abuse: Neglect

Plain-language summary

A complaint was investigated regarding failure to properly plan care. The outcome of that investigation was not determined or documented in the available information. Families seeking details should contact Oregon DHS Long-Term Care Licensing directly for the final determination.

Abuse: NeglectOAR §__or_433a5fd03cc783339aa6060700ff740b
Verbatim citation text · OAR §__or_433a5fd03cc783339aa6060700ff740b

Failed to properly plan care

Full inspector notes

—: Failed to properly plan care

2024-01-27
Complaint Investigation
1 · Abuse: Neglect

Plain-language summary

A complaint investigation found that the facility failed to properly plan care for a resident. No further details about the specific care planning deficiency or its impact were provided in the inspection documentation.

Abuse: NeglectOAR §__or_d1eb30c541c780fb86439be3d61493cc
Verbatim citation text · OAR §__or_d1eb30c541c780fb86439be3d61493cc

Failed to properly plan care

Full inspector notes

—: Failed to properly plan care

2024-01-22
Complaint Investigation
1 · Abuse: Neglect

Plain-language summary

A complaint was investigated regarding failure to follow a resident's care plan. The investigation did not substantiate the complaint—no violation was found.

Abuse: NeglectOAR §__or_75dafabd10fe61a3095e30052d614447
Verbatim citation text · OAR §__or_75dafabd10fe61a3095e30052d614447

Failed to follow care plan

Full inspector notes

—: Failed to follow care plan

2024-01-11
Complaint Investigation
1 · Abuse: Neglect

Plain-language summary

A complaint investigation found that the facility failed to properly plan care for a resident. No further details about the specific care planning deficiency or its outcome were documented in this report.

Abuse: NeglectOAR §__or_2e163506988de5a8b501712c8e7384e3
Verbatim citation text · OAR §__or_2e163506988de5a8b501712c8e7384e3

Failed to properly plan care

Full inspector notes

—: Failed to properly plan care

2024-01-09
Complaint Investigation
1 · Licensing Violation

Plain-language summary

A complaint investigation found that the facility failed to administer medication as ordered. The complaint was substantiated as a licensing violation. The facility is required to correct this deficiency.

Licensing ViolationOAR §__or_e342060ea5c28b391a1af6f71deb9075
Verbatim citation text · OAR §__or_e342060ea5c28b391a1af6f71deb9075

Failed to administer medication as ordered

Full inspector notes

—: Failed to administer medication as ordered

2024-01-01
Complaint Investigation
1 · Abuse: Neglect

Plain-language summary

A complaint was investigated that the facility failed to follow a resident's care plan. The outcome of that investigation has not yet been determined or released.

Abuse: NeglectOAR §__or_4f9034358cc75f9d1084fa99ae2c9273
Verbatim citation text · OAR §__or_4f9034358cc75f9d1084fa99ae2c9273

Failed to follow care plan

Full inspector notes

—: Failed to follow care plan

2023-12-31
Complaint Investigation
1 · Licensing Violation

Plain-language summary

A complaint was investigated regarding failure to administer ordered medication. The investigation outcome was not specified in the available information. Families should contact Oregon DHS Long-Term Care Licensing directly for details on whether this complaint was substantiated and what corrective action, if any, was required.

Licensing ViolationOAR §__or_09ab1e7a9bf078c521fbb561d64a6434
Verbatim citation text · OAR §__or_09ab1e7a9bf078c521fbb561d64a6434

Failed to administer ordered medication

Full inspector notes

—: Failed to administer ordered medication

2023-12-18
Complaint Investigation
No findings
2023-12-01
Complaint Investigation
1 · Licensing Violation

Plain-language summary

A complaint investigation found that the facility failed to report potential or suspected abuse as required by state law. The facility did not meet its mandatory reporting obligations under Oregon regulations. This is a licensing violation.

Licensing ViolationOAR §__or_570fa0e902913855f6a91c1c3489592b
Verbatim citation text · OAR §__or_570fa0e902913855f6a91c1c3489592b

Failed to report potential or suspected abuse

Full inspector notes

—: Failed to report potential or suspected abuse

2023-11-29
Complaint Investigation
1 · Abuse: Neglect

Plain-language summary

A complaint was investigated regarding failure to provide service. The outcome of that investigation is not documented in the available information. Families seeking details about what service was not provided or what findings resulted should contact Oregon DHS Long-Term Care Licensing directly.

Abuse: NeglectOAR §__or_f172e020953cddbfaed5e08f92947d4e
Verbatim citation text · OAR §__or_f172e020953cddbfaed5e08f92947d4e

Failed to provide service

Full inspector notes

—: Failed to provide service

2023-10-24
Annual Compliance Visit
No findings
2023-10-11
Annual Compliance Visit
No findings
2023-08-21
Complaint Investigation
1 · Abuse: Neglect

Plain-language summary

A complaint was investigated alleging the facility failed to provide a safe environment. The investigation outcome was not substantiated, meaning no violation was found. The facility was not cited for this complaint.

Abuse: NeglectOAR §__or_54b042db14b35fb81dbe5e19080bb4b7
Verbatim citation text · OAR §__or_54b042db14b35fb81dbe5e19080bb4b7

Failed to provide safe environment

Full inspector notes

—: Failed to provide safe environment

2023-08-07
Complaint Investigation
1 · Licensing Violation

Plain-language summary

A complaint was received that a resident experienced verbal abuse, but the investigation found no violation occurred. The facility was not found to have failed in its duty to protect the resident from verbal abuse.

Licensing ViolationOAR §__or_746f46088be8ee2447b3a9868076deea
Verbatim citation text · OAR §__or_746f46088be8ee2447b3a9868076deea

Failed to protect resident from verbal abuse

Full inspector notes

—: Failed to protect resident from verbal abuse

13 older inspections from 2022 are not shown in the free view.

13 older inspections (20222023) are available with a premium membership.

§ 07 · Nearby

Other facilities in Clackamas County.

Other memory care facilities in Clackamas County with similar care offerings.

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