An Auckland retirement village has been criticised over lapses in its care of an elderly woman who suffered a fall and later died.

Deputy Health and Disability Commissioner Rose Wall has named the village - Aria Park Senior Living Ltd, part of the Arvida group - in a report dated May 13 which she has made public today.

Wall said the woman's fall in 2016 was not seen by others. What her carers did notice later the same day was that she was having difficulty standing, a problem that later got worse.

The woman, whose age and name are not stated in Wall's report, had been at the village since 2010. In 2014 she was assessed as requiring private hospital-level care owing to her increased frailty.

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She was not taking regular pain medications but had been prescribed to take, as needed, morphine, paracetamol and codeine.

She complained of right leg and right arm pain the day after the fall. A day later when she was being moved in a transfer belt, the belt unclipped and she was lowered to the ground. Her pain got worse, she was seen by a GP and taken to hospital by ambulance.

An elbow fracture was found and the woman, "Mrs A" in the report, was taken back to the village with instructions to continue her regular pain relief regimen, but that did not occur.

Her pain intensified in the following days and she was taken back to hospital. A CT scan showed a pelvic fracture and shoulder injuries.

"Sadly, Mrs A's condition deteriorated and she died," Wall's report said.

A coroner found the woman died of natural causes; she had pneumonia and heart trouble. The injuries from her falls probably contributed to her death.

Wall said there were "serious issues" with the care provided at the village by various staff. The village itself carried overall responsibility for ensuring the woman received care of an appropriate standard.

She concluded the village had breached the Code of Health and Disability Services Consumers' Rights, by failing to provide services with reasonable care and skill.

She found failures in the village's pain assessment and administration, incident reporting, documentation, compliance with its manual-handling policy and communication. There were also delays in obtaining a GP review and in contacting an ambulance.

But Wall also said she was satisfied there had been positive changes at the village since the woman's fall and episode of inadequate care.

She recommended the village report back to her on education it provided to staff; improvements in documenting the administration of medication; the process to support the use of restraint and restraint-use documentation; incident reporting; and the process of seeking medical attention and transferring a resident's care to a hospital.

The Village's manager, Hyrum-Daniel Dennis, said: "We accept the findings of the HDC and have apologised unreservedly to the family.

He said the incident occurred in May 2016, 10 months after Arvida took over and had started an overhaul of Aria Park, including reviewing and introducing new policies and processes.

"The wellbeing and care of our residents is paramount. The HDC report notes Aria Park has undertaken considerable work after the incident, including launching a renewed and thorough education plan for all staff around reporting, communication, care planning, observations and recordings."

Dennis noted that following the improvements and changes at the village it received a four-year Ministry of Health certification in April last year.