A Lower Hutt resthome is being investigated over complaints of physical and verbal abuse, neglect and intimidation of residents and staff.
The Hutt Valley District Health Board is looking into five complaints at the Woburn Masonic Care home - four last year and one this year.
One unidentified staff member emailed the Health and Disability Commissioner, warning that "someone will die needlessly and before their time if someone does not look more closely at this resthome".
An independent advocate spoke to multiple residents in 2019 and reported them saying they felt "scared and intimidated" to raise concerns about their care with management.
The home told the commissioner that resident surveys showed high satisfaction and feelings of safety.
It was "very confident" managers and staff had acted appropriately.
The commissioner closed each of its own investigations, saying in some cases it couldn't determine what had gone on, but was "sufficiently concerned" that in April this year it alerted the DHB.
The DHB investigation is still going on six months later at the 57-room home in the Hutt's most upmarket suburb.
"We continue to investigate all of these matters to ensure the safety of the residents," DHB chief executive Fionnagh Dougan told RNZ in a statement.
Woburn passed its last independent audit in 2018 without incurring any high-risk red flags.
The five complaints are among 107 received by HealthCERT this year, and 132 last year, against certified healthcare providers.
'So much bullying and fighting'
Two of the five complaints are from a family saying their mother's care had been poor, with one going as far as to say this contributed to her death.
The commissioner does not agree with that, saying the home was "attentive" to the woman's pain; nevertheless, the HDC was "concerned" at reports of theft and "intimidation by staff".
Two unidentified staff complained about rough handling of residents, including pushing, with one elderly man being told staff were "sick of his shit" and to "get out", it was claimed.
In the other case, the complainant said a tense situation was made worse needlessly because of a lack of skill.
Another unidentified staffer, in long emails to the HDC, claimed "two of our residents died and they really didn't need to".
Staff were in short supply and care was being missed or hurried; "There is so much bullying and fighting," they said, without it being clear just who was fighting who.
Staff expressed fear they would be punished for speaking out.
The National Health and Disability Advocacy Service, an independent trust that handles 3000 complaints a year, met residents at the home for an hour in 2019.
Multiple residents spoke of feeling "intimidated and scared when raising concerns to management" about their care, the advocate wrote to the HDC.
A common concern was "fear of being removed from the home".
Satisfaction and safety plus-90 percent
The home's management defended its care in each case to the HDC.
The home's new manager had made "important changes" to support residents and families.
The home scored in the 90s percentage-wise in surveys of resident satisfaction and their feeling safe to speak up - above industry benchmarks, it said.
Staffing exceeded recommended minimums, it added.
Warick Dunn, chief executive of the Masonic Villages Trust that runs the home, would not be interviewed but in a statement to RNZ said: "We are all disappointed that these complaints have been made but I am very confident we and our staff have acted appropriately in this matter."
The home took patient care and safety extremely seriously, and had co-operated fully with the HDC investigations, he said.
It was waiting for the DHB to undertake its review, Dunn said.
The Hutt Valley DHB has not spelt out how it is ensuring everyone is safe, saying only that it was "working with" the home.
When RNZ asked if more regular monitoring was occurring, or if it had made it easier for residents to speak up, the board said it was "inappropriate to comment on actions undertaken until this process has been completed and findings and recommendations have been determined".
The DHB, and the ministry's HealthCERT quality control body, were "able to take action promptly", the Health and Disability Commissioner said in the OIA documents.