When Bozena's father turned up bleeding from being "thrown around like a dog" by staff at Bupa Stirling, she demanded an explanation from the residential aged care facility's management.
The worker responsible was fired and the problem addressed, she says, but the inadequate care continued - each instance tarnishing her intent to "cradle" her parents into the end of their lives.
"I was virtually there everyday, or telephoning every day. If I didn't, things were not happening," Bozena, who asked for her surname to be withheld because of privacy concerns, said.
"My dad kept telling me, 'At night, I'm being treated like a dog. They're throwing me around, they're pushing me around'.
"That was a clear lesson."
Bozena's father passed away in February 2018, a little more than a year after he moved in to the facility after a fall. Her mother fell into a coma from which she did not wake up on February 13, 2019.
That same day, Bupa Stirling was hit with a nine-month sanction; the Department of Health having identified issues such as medication management, pain management, and lacking systems to ensure residents' quality of life.
Sanctions require issues to pose a "severe and immediate risk" to a facility's residents.
Bozena says her parents' time at Bupa Stirling was scattered with "warm, marvellous staff", but others seemed to lack training and direction.
She recalls returning from a 10-day holiday to find her mother had not been washed in two weeks. Clothes were frequently left on the floor and on the furniture, and dead flowers would often be rotting in a vase.
"We are very sorry to hear of this family's experience, and we are committed to making improvements at the home," a Bupa spokeswoman said.
Kambah resident Kerry Evans, whose 79-year-old mother Yvonne Emery has lived at Bupa Stirling since December 2017, says she experienced similarly inadequate care.
Sometimes she found her mother had not been taken to the bathroom and was wet with urine. Other times, she had been dressed haphazardly with two different slippers, or her walker was not left next to her bedside.
"My mum worked until she was 76 full-time. She's paid all of her taxes and I feel like this is now how she's being treated: with no respect," Ms Evans said.
Food at the facility had improved since the sanction was handed down, Ms Evans said, but there had only been a slight improvement in care and communication between staff and residents.
Improvements being made at Bupa Stirling included appointing a new general manager, recruiting new staff, reviewing resident care plans, and bolstering training and education, the spokeswoman said.
Independent advisers had also been appointed as a requirement of the sanction, and the facility was not being given any Commonwealth funding for new residents until it expired.
"Bupa is taking the sanction notice extremely seriously. We know that we have let down our residents and their families, and we are very sorry for this," the spokeswoman said.
"We are committed to implementing the necessary changes as quickly as possible, and providing the care that our residents expect and deserve."
Five residential aged care facilities in the ACT have had sanctions in the past five years. They include Pines Living in Farrer, whose notice related to continence management, emotional support, and infection control, among other things.
Pines' sanction expired in May.
The facility's general manager said it would not comment on the issue because of time constraints. It was still being monitored by the Department of Health and the Aged Care Quality and Safety Commission.
A full list of residential aged care facilities' sanctions in Canberra, including their details, is available on the My Aged Care website.
It also includes information about notices of non-compliance, which are lesser warnings given to facilities to identify what they need to improve on.
Aged care navigator and chief executive of Independent Care Solutions, Luisa Capezio, said it was important for prospective aged care home residents to do their research when it comes to a facility's history.
We know that we have let down our residents and their families, and we are very sorry for this.Bupa spokeswoman
"One of the most important things when we're identifying an aged care facility for our clients ... is [looking at their history]. Part of that is has it been sanctioned or not," she said.
"If it has [been], we do recommend, and what we organise, is a meeting with a manager of the aged care facility to explain why [it was sanctioned] and what changes they've put in place."
Chief executive of the ACT's Council of the Ageing, Jenny Mobbs, said sanctions would likely be a deterrent to people looking at facilities. They also had a "backing up" effect on the territory's hospital system.
"People who are actually well enough to go to a residential care facility can be languishing in hospital for extra care days," Ms Mobbs said.
"While residential care is a federally funded issue, it [goes] back to ACT Health and adds to the cost of the hospital."
New aged care quality standards, which focused more on residents rather than on a facility's processes compared with current standards, would come into effect on July 1.
Ms Capezio expected they would make facility's more wary of how they were treating residents, and better care might be expected as a result.
"For me, that's a massive change and a positive shift compared to what we're living and breathing with the current standards [which are] very process-driven," she said.