The senior living facility where one woman died from a poisoning after she was mistakenly given cleaning solution to drink, has faced multiple complaints from previous residents, according to a complaint investigation report obtained by KTLA sister station KRON.

Atria Park Senior Living facility in San Mateo said the woman, 93-year-old Gertrude Elizabeth Murison Maxwell, was among three residents with dementia who had mistakenly been served a dishwasher detergent instead of drinking juice.

For Atria Senior Living, a company with more than 200 locations across 28 states and Canada, including three facilities in the East Bay and another five across the South Bay and Peninsula, it wasn’t the first time that the company had received complaints or allegations of negligence.

In 2018, Atria Park was named in a lawsuit brought by the family of an 86-year old woman who experienced injuries while in the facility’s care. In July 2019 the California Department of Social Services conducted an unannounced visit to Atria Park after a complaint was received the previous October.

The allegations listed in the complaint investigation report include that the resident sustained multiple unexplained injuries while under the care of facility staff, and that facility staff failed to provide a safe environment for the resident.

Over an approximately five-hour visit of the facility, the CDSS evaluator found that the allegations were substantiated by medical records. The woman reportedly suffered a head injury and laceration in February 2021, a pubic ramus fracture in April 2021, and many unexplained falls throughout her short time at the facility. The woman later died in November 2021.

The report goes on to state that Atria did not meet the patient’s requirements for safe and healthful accommodations, and therefore her personal rights were violated. An allegation that the facility staff failed to administer medication as prescribed and accurately document the disbursement of medication in a log was found to be unsubstantiated.

In March 2021, the same investigator conducted another unannounced visit to Atria Hillsdale due to a 2020 allegation that a resident had experienced a stage 4 pressure injury — commonly known as a bed sore — while in the facility’s care. The investigation revealed that on March 26, 2020 Atria staff began treating what was a stage 2 wound. On April 6, 2020 a licensed vocational nurse at the facility noted that the wound had progressed to stage 3.

According to California Code Regulation 22 § 87615, a stage 3 wound is a “prohibited health condition,” or a condition that calls for the patient to be automatically transferred to a hospital for further care. The investigation revealed that though a client had suffered a prohibited health condition, the facility “failed to seek a higher level of care,” according to the report.

By the time Atria sought medical care for the client, the wound had progressed to stage 4. According to John Hopkins, a stage 4 bed sore is one that has progressed into, “muscles, tendons, bones, and or joints,” and, infection is a significant risk at this stage. The investigation found that Atria did not ensure “competent staff” was treating the client’s wounds. Atria was issued a civil penalty for $500 due to the incident and later cited.

In July 2021, another inspection was completed at Atria by a different CDSS employee who found that criminal background checks were not on file for two staffers, one of which had already had direct contact with patients. According to the Plan of Correction the facility was expected to provide the necessary data to correct the error the same day.