A rest home has been temporarily taken over by the Auckland District Health Board after an unannounced inspection found evidence of neglect.
The Ministry of Health's audit of Sylvia Park Rest Home and Hospital in Mt Wellington in July was prompted by a complaint from the Health and Disability Commissioner.
The complaint raised serious concerns about the safety of vulnerable residents.
The DHB, which contracts the rest home, appointed a temporary manager to run the 47-bed facility following the inspection.
The inspectors' report found shortfalls in clinical care, incident reporting, infection control, procedures for patients with catheters and hours worked by staff.
The clinical nurse manager at the time of the inspection was suspended with pay and has since left the rest home.