After meeting residents and staff this month, the DHB spurred the trust to bring in a new temporary manager, as well as take on two DHB personnel in clinical support.
Last month the 57-bed home was slated by the trust to be shut down and rebuilt.
The woman, who has not been named, had lived at the home for several years, when she died two years ago after two falls.
Her son Nigel Evans, a Wellington public servant, praises the nurses and carers - saying the staff were let down.
"The issue is largely in relation to rostering and the thinness of resource, particularly at the weekends," he said.
"Weekends, I was always fearful.
"I never knew if there was going to be staffing at the level that would be able to look after mum."
Supply nurses at the weekend often appeared unfamiliar with rest home work and did not have time to check the residents' notes, Evans said.
The home's management did not keep up with recording what level of care his mother needed, he added.
"After a fall, clinicians at the hospital in the Hutt ... went through a helluva job to try and actually determine the level of care my mother would receive on being returned to the nursing home."
As it was not indicated on her records, he said "the staff at that time had no idea".
Hydration, and fall risks, were not managed properly when she returned to the Woburn home, Evans said.
"The fact that the fall prevention systems were not in place in her room, is just extraordinary.
"It accelerated things tremendously."
"On her second fall, [she] was bleeding profusely ... the shock to her system absolutely accelerated her decline."
The wider systemic issues with an elder care system that was under-resourced even as a "tsunami" of demand was placed on it, had to be dealt with, Evans said.
"There must be something missing in terms of the auditing process because it's clear to me that this pattern of management failure, negligence, and general lack of focusing on the fundamentals in relation to the care of the elderly, that had not been monitored well."
It was difficult to know if Woburn was an isolated case in a system that lacked monitoring, he said.
Evans did not lodge a complaint about the home, saying he was in shock and grief towards the end of his mother's life, and had had upsetting run-ins with management.
"And to be honest, you know, what's happening now is really very, very positive in my mind ... but at the time that my mother was actually in the circumstance, I did not feel as though I could say anything. I was fearful."
It echoes some of the complaints that sparked the investigation.
A National Health and Disability Advocacy Service advocate noted, after a visit to Woburn months ago, that multiple residents spoke of feeling "intimidated and scared when raising concerns".
The Masonic Villages Trust declined to comment on this case or Nigel Evans' claims, as did the Hutt Valley DHB.
The trust said it was working with the health board to ensure standards of care were met.
The final DHB investigation report is due out in late January.
