SAN MATEO, Calif. (KRON) — The senior living facility where one woman died from a poisoning on Monday has faced multiple complaints from previous residents, according to a complaint investigation report obtained by KRON4.

Atria Park Senior Living facility in San Mateo told KRON4 yesterday that three residents had mistakenly been served a dishwasher detergent instead of drinking juice. Atria Senior Living is a company that supports more than 200 locations across 28 states and Canada, according to their website. Atria has three facilities in the East Bay and another five across the South Bay and Peninsula.

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 of 2019 the California Department of Social Services conducted an unannounced visit to Atria Park after a complaint was received in October 2018.

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 the evaluator listed as Bertha Raygoza found that the allegations were substantiated by medical records. The woman reportedly suffered a head injury and laceration in February of 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.

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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 of 2021, Raygoza 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 under Section 87405 (d) (1).

In July of 2021 another inspection was completed at Atria by CDSS employee Audrey Jeung. Over her nearly 6-hour tour of the facility she 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.

Atria Senior Living shared the following statement with KRON4:

In 2018, there was an incident at our Atria Park of San Mateo community where a resident sustained a fall that resulted in an injury. Our staff immediately sought medical attention and notified the resident’s family. The safety and wellbeing of our residents are our highest priorities, and we take these incidents very seriously. We worked closely with state regulators to address this matter, and the deficiency itself was revoked.

Atria Senior Living