Two residents at Warrigal Warilla "died in distress, with unrelieved pain and discomfort" according to a damning report released this week.
Dementia patients were also observed wandering aimlessly and calling out "with no meaningful lifestyle interventions" during a five-day audit of the facility by a Federal Government agency in January.
Meantime the Aged Care Quality and Safety Commission detailed numerous reports of care recipients being found in wet beds, as well as others roving the home at night and entering other residents' bedrooms.
The unannounced audit was undertaken soon after a 48-year-old female worker was charged over alleged assaults of five elderly residents at the home. Shakuntala Mudaliar, who was immediately stood down, will defend the charges at a hearing set down for Wollongong court in November.
The Federal health department slapped sanctions on the Arcadia Street facility immediately after the audit, citing an "immediate and severe risk to the health, safety and well-being of care recipients".
This week the Commission publicly released its full audit report, which revealed the Warilla facility met just 24 of the 44 national standards of care.
Many of the failures were within the vital area of health and personal care where 13 of 17 needs went unmet; including medication and pain management.
"The home's monitoring system does not identify errors related to medication administration," the report stated. "... Pain is not assessed or monitored to develop strategies for management of care recipients experiencing pain."
Nutrition and hydration, and skin care were other areas of concern, with "significant gaps in wound care provision" identified.
"Injuries in the form of skin tears and bruising are not monitored and evaluated to minimise recurrence," the report stated.
There were "poor continence care practices", with auditors observing numerous reports of care recipients in wet beds. Behavioural management also fell down, with a number of residents' "unmanaged wandering behaviours" impacting others.
"There are numerous care recipients who wander the home at night and are intrusive into other care recipients bedrooms," the report said. "There is high incidence of challenging physical aggression.
"...Care recipients said at times the home is noisy at night which impacts on their ability to sleep."
Meantime the audit found the "comfort and dignity of terminally ill recipients is not maintained.
"Review of two recently deceased care recipients' files found both care recipients died in distress, with unrelieved pain and discomfort; their dignity was not maintained," it stated.
"The home is at times noisy, there are minimal private spaces and bedrooms are all shared with many four-bedded bedrooms.
"Behaviours of other care recipients impact on the terminally ill."
The home, of 78 residents aged from 82 to 98, did meet most of the standards relating to its physical environment.
"The service's environment reflects the safety and comfort needs of care recipients, including comfortable temperatures, noise and light levels, sufficient and appropriate furniture and safe, easy access to internal and external areas," the report stated.
Warrigal has until July 16 to meet all standards, or else it could lose its approval as an aged care provider.
It will also receive no Commonwealth subsidies for any new care recipients, and has had to appoint an administrator and provide staff training.
Warrigal CEO Mark Sewell said the Warilla home had appointed an administrator, a clinical advisor and new management team who had already overturned a number of negative outcomes from the audit.
"We have received very positive feedback from the department on progress so far. The department monitors our progress weekly and the Warrigal team is confident the remaining unmet outcomes will be resolved in the near future," he said.
"We want to again let our residents, families and the community know how embarrassed and very sorry we are that this recent situation occurred.
"We are now turning this situation around very quickly and expect to have the special restrictions lifted sooner than the six months that the department has allocated.
"We are beginning to again earn the enormous trust that we have had from the residents who live there, their families who chose the home for their loved ones and the wonderful community around the home who have supported it for many years by volunteering in the home and visiting it."
Mr Sewell said 31 residents were mentioned specifically in the audit as being in need of improvement to their health management.
"All of these residents have had a complete health and medical review and we will be implementing every recommendation made by the doctors, nurses, and other health professionals engaged in the review," he said.