For the vulnerable residents of Earle Haven's high care facility, the evacuation from their home in July came without warning.
Husbands and wives of more than six decades were separated - some with only the clothes they were wearing.
Walkers, dentures and hearing aids were left behind.
One family told an inquiry into the sudden closure how their loved one was taken to a new facility in the dark, in the middle of a winter's night.
Within seven minutes of arriving, they fell and were admitted to hospital with a subdural haematoma, the family told the inquiry by former ACT chief minister Kate Carnell.
Like many others, the family found about about the turmoil unfolding at Earle Haven through the media, her report says.
They contacted the home and were told there were "no problems" and "don't come in".
The next call was after midnight to tell them their loved one was in the hospital.
The resident never recovered and died five weeks later.
The family said their loved one was "never the same" after the fall and was denied a dignified end of life.
In all, eight residents were sent to hospital after being relocated to other residential aged care facilities and three have since died.
The report released on Monday reveals a bitter dispute between the approved aged care provider People Care and its subcontractor Help Street Villages led to the shutdown. It came after Help Street demanded $3.9 million it said it was owed.
Australian Associated Press
