His daughter told the HDC she felt the lack of action and basic care provided to him may have been a contributing factor to his death.
Various blind spots in Mr A's care were heavily criticised by Wall, primarily around monitoring his weight loss, lack of nutritional planning, monitoring of his food and fluid intake, and communication to his daughter.
"The failure to deliver those fundamentals meant that staff did not recognise that his condition was deteriorating and sadly he passed away," Wall said.
Food intake and unintentional weight loss were found to be key failings by the home, and his dementia - which can lead to weight loss - wasn't taken into account.
Mr A's health began deteriorating in 2018 and a few months later he was diagnosed with bowel cancer. Two months after the diagnosis he died.
From the beginning of the period which was under investigation, Mr A weighed 71.7kg and at the time of his last check-up weighed 59.8kg.
Eating was difficult for Mr A. Sometimes his poor eyesight contributed to this as he couldn't see his food.
His daughter said there were occasions when full plates of food were taken away while she was visiting.
His continual weight loss should have prompted a weight loss report to be completed by the home on multiple occasions, but according to the report, only one was completed.
The daughter said rest home staff did not keep her updated on her father's care, a situation admitted by the home which said because Mr A's son lived locally and visited daily that updates were provided to him.
Wall said proper communication with a resident's power of attorney - which the daughter was - was critical, especially when a patient was showing a decline in health.
In her report Wall said effective care planning for aged-care residents was vital to capture the needs of residents and ensure appropriate care is provided.
"This suggests that staff consistently and repeatedly failed to appreciate the deficiencies in Mr A's food and fluid intake between month one and month eight.
"This is concerning, particularly given that his diagnosis of dementia placed him at an increased risk of unintended weight loss."
Despite receiving two-yearly training, the nurses involved in the man's care failed to think critically and adhere to the internal policies in place at the rest home.
"In my view, it is the responsibility of the rest home to ensure that its staff are aware of their obligations and are providing services consistent with accepted practice," Wall said.
While the deputy commissioner said she was concerned about the lack of oversight of Mr A's care plan, she was also of the view that all staff involved with a patient's day-to-day care were responsible to recognise signs of deterioration in a resident's general condition.
"It is clear that there was a lack of critical thinking, and the various staff at the rest home repeatedly failed to recognise the significance of Mr A's weight loss, which was documented each month," Wall said.
"This is evident by the failure of staff to take adequate steps to address it. By not taking any action, staff also failed to adhere to organisational policies in relation to weight loss."
It was concerning to Wall that there was a lack of critical thinking by staff and consideration of reasons for Mr A's declining health, and deficiencies in his care led to the care home failing to provide basic care "on many occasions".
"Mr A's subsequent bowel cancer diagnosis suggests that other factors may well have been at play and may have contributed to his loss of appetite and weight loss," Wall said.
