Kate Davis assumed death would be part of an aged care facility's core business.
But she found the Canberra facility and its staff were not equipped to handle her mum Noeline Taylor's final days.
Ms Davis said staff did not recognise that her mother was in the end stage of her life.
"I think we all assume that a core business for an aged care business is death," she told the aged care royal commission on Wednesday.
"It might be okay if you just passed away in your sleep but if you have any kind of extended death they are just woefully ill-prepared, in my experience."
There were small things, like shocked carers not realising Ms Taylor was "beyond the point of eating".
Some staff were upset when they saw Ms Taylor, which Ms Davis said only added to her own distress and concern over their ability to look after her mum.
There was also a distressing incident when Ms Taylor was moaning in agony for three hours as there was no nurse to give her pain medication.
Specialist palliative care nurse Nikki Johnston, who had supported the family for several months, organised for Ms Taylor's transfer to a hospice where the 83-year-old died in August 2015.
"The care provided was so professional, it was directed at an actively dying person and was instrumental in ensuring Mum died free of pain and suffering," Ms Davis said.
Ms Johnston said palliative care training for aged care staff was important.
"They lack the knowledge and skills and it's not because they don't care. It's just that they've never been taught."
While this week's evidence included aged care residents being hospitalised when it was unnecessary or avoidable, Ms Johnston gave the example of a 105-year-old woman who broke her hip and was turned away from a hospital.
"Because her advance care plan said not for resuscitation, they didn't even get her out of the ambulance and they sent her back to the nursing home with no pain relief," Ms Johnston said.
Melbourne aged care resident Hamish MacLeod told the inquiry about his difficulties in accessing medical care for health problems including diabetes, kidney issues and macular degeneration.
The 74-year-old has to walk 650 metres to his GP's clinic and spends an hour and a half on public transport getting to specialist appointments.
"I think that it should be easier to access quality GPs and specialists," Mr MacLeod said in a statement, after health issues stopped him appearing at the Canberra hearing.
"I think that it should be easier to get quality health care within residential aged care facilities."
Australian Associated Press