Inspectors from the federal Aged Care Quality Agency visited the Adria Village nursing home in July, finding that these issues could put its elderly residents at "serious risk".

"Management is not able to demonstrate care recipients' medication is managed safely and correctly," inspectors wrote in their report.

"The medication auditing and reporting system does not include the administration of insulin.

"There are a number of pharmacy-related errors identified every month in the auditing system, and the pharmacy is unable to assist in the provision of suitable medication charts for care recipients on respite."

Inconsistencies with the treatment of dying patients in palliative care were also singled out by inspectors.

"There are systems to ensure the comfort and dignity of terminally-ill care recipients, however the processes surrounding these systems are not always followed," they wrote.

"Documentation and staff discussions show the spiritual, cultural, psychological and emotional needs of care recipients are considered, but time is not always available for staff to ensure these needs are met."

Another area criticised in the report was the provision of clinical care, with a particular emphasis on the facility's response to accidents.

"There is a breakdown in the management and review of care recipients' incidents and accidents resulting in clinical care not being appropriately provided," inspectors said.

The other two standards that Adria Village did not meet were "human resource management" and "information systems".

"The home does not have a system to ensure there is enough appropriately skilled and qualified staff to meet the needs of care recipients," inspectors wrote.

"Deficiencies in information management are adversely impacting on care recipients' clinical care, medication management and palliative care," they continued.

Although Adria Village did not meet these five standards, they did pass the other 39 outcomes they were assessed against.

Inspectors commended the actions the facility had taken to review and improve their quality of service.

"A plan for continuous improvement is used to track the improvements being undertaken by the home.

"Quality indicators across key areas such as infections, falls and incidents are monitored on a routine basis."

General manager of Adria Village Iva Vujica said the facility was working alongside government officials to further address the issues raised.

"We are continuously working with the Department and the Agency and won't be making any further comment," she said.

The government has imposed sanctions on the facility to address the "immediate and severe risk to the health, safety and wellbeing of care recipients".

These sanctions are:

The Aged Care Quality Agency has also limited the facility's accreditation period until 31 January, 2018.

"The short period of accreditation will provide the home with the opportunity to develop and implement effective monitoring systems while addressing the areas identified as not met," the agency said.

The online Aged Care Guide describes Adria Village, in the suburb of Stirling, as a 40-bed facility with 12 permanent places for residents with dementia.

It was audited across 10 days in July, with 17 care recipients and about 20 staff interviewed in the process.

Concerns about the facility were first uncovered by The Canberra Times in July, although specific details could not be revealed until the government finalised its inspection report.