Mrs B (the mum) told the HDC that her main concern was not so much about how the burns came about, but rather how her daughter was left to suffer for so long.
Names have not been used in the report due to privacy reasons.
While under SJOG care in 2019, the woman's continence product leaked and left severe urine burns to both thighs, the report said.
The investigation found there was a 12-hour delay to monitor and replace the continence product and that it was not in the right position and was too large.
It also found there was also a lack of frequent pain assessments, inadequate medication administration, inconsistent documentation, a failure to seek a timely medical review, and insufficient communication with the woman's welfare guardian.
SJOG told HDC: "A great deal of reflection has taken place by all staff involved in this event.
Staff have been very concerned that due to a lapse in ensuring best practice, [the woman] received an injury which resulted in a decision being made to move her to another facility."
The Deputy Commissioner criticised SJOG, saying they failed to provide services with reasonable care and skill, and in a manner that respected the woman's dignity.