The Anglican Care-run Greenmount Gardens, at Mount Hutton, has also failed to meet industry standards for wound care and pain management.

During an on-site assessment conducted in April, one of the residents said she was "constantly in pain with no relief" and no one "has asked how she is".

Residents also said that staff were "always very busy" and they must sometimes wait "a long time" to get help, according to a report published by the federal Aged Care Quality and Safety Commission.

The assessment team said staff could not describe how infection related risks were minimised, and there was a lack of timely referral to behavioural specialist services.

"Pain is not monitored or evaluated effectively for consumers .... Two consumer's wounds have deteriorated and there has been a lack of wound specialist review for one consumer."

A review of wound charts found that wound reviews were not always adhered to and they did not have specialist wound reviews.

Residents and staff also said they were unable to manage the behaviours of one resident who wandered, was intrusive, and entered other people's rooms after hours.

The home's psychotropic registered showed that 35 out of 39 residents were on psychotropic drugs without written consents from residents' representatives.

Staff were interviewed and said they were short staffed and time poor and could not "do everything'' for the residents.

In a letter to residents, family and friends, dated July 1, Executive Director Andrew Wind said he was disappointed in the outcome and he regretted that the facility did not meet the high standards of care that it was expected to.

"I have spoken to Bishop Peter Stuart, the Chair of our Board ... and outlined to him the commitment of our staff to meet and exceed the standards expected of us," the letter said.

A 'continuous improvement plan' would be completed by August and included increased nurse coverage, improved processes around the prescription and administration of medication, staff education on wound care, pain and medication management, and improvements to care planning processes.

Anglicare had engaged a senior clinical pharmacist to help ensure mediations were reviewed, monitored and consents provided, and an external consultant had reviewed all wounds since the audit, a statement issued by Anglicare on Wednesday said.

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