An audit assessment team also observed staff rushing tasks and walking past a resident, who was calling out for help without stopping to offer assistance.

The findings of non-compliance in three out of four categories indicated shortfalls across care, pain management, staff skills, observation and wounds - which covered the majority of services provided in the nursing home.

Lyndoch got a pass for infection control - "while there was poor practices noted, on balance, the approved provider complies with this requirement", the report found.

The audit by the national peak body Aged Care Quality and Safety Commission was conducted in late January, the report was released in March and became public knowledge late Tuesday night.

Comment is being sought from Lyndoch Living and Federal Member for Wannon Dan Tehan.

In 2015 and 2018 audits Lyndoch achieved 100 per cent compliance before one non-compliance result in 2018.

The audit assessment team (AAT) found Lyndoch did not demonstrate care that was tailored to the needs of sampled residents.

One resident prescribed regular anti-psychotic medication was classified as being 'chemically restrained' but there was no record of consent having been obtained and a representative of the resident said they had not provided consent and were unaware of any potential side effects.

Lyndoch stated to the AAT this was was not a systemic issue.

The report found not all residents sampled were receiving tailored care and/or the approach to their care was not always best practice.

Pain charting was inadequate, on some occasions staff were unable to deliver care due to a resident's behaviours and even when a specialist recommended an increase to a resident's pain medication that did not happen.

Lyndoch strongly refuted the findings that staff failed to provide care, but the report noted a review of progress notes supported that staff were "facing challenges".

The same resident also had several wounds, and the assessment team found these were not adequately overseen by clinical staff.

An initial wound treatment plan did not indicate the dimensions of the wound although one photograph, taken eight days later, did show the wound dimensions against a ruler, but it was unclear if the wound was deteriorating or resolving.

The AAT also reviewed Lyndoch's mental state drug records and found them to be out of date.

Lyndoch was also found non-compliant with the effective management of high impact or high prevalence risks.

Staff did not undertake a timely review of one resident's pain on return from hospital after a fall and head lacerations which required an overnight hospital stay.

And they did not then undertake neurological observations.

A physiotherapist's review was noted as timely, but a tender shoulder and an order for stronger pain relief was not processed until two days later.

Staff reflected on the increasing needs of residents, in particular an increase in residents exhibiting behaviours of concern and how multiple staff supporting high need patients resulted in less care or supervision of others.

A review of the roster across a two-week period identified some shifts were unfilled.

While Lyndoch demonstrated that it had made efforts to train and recruit staff and the number of staff had not been significantly changed, the skills of the current mix of staff delivering the care were inadequate and were not meeting the current needs of residents, the report found.

"This deficit in skills is evident as the quality of clinical care being delivered is not to the standard required by the Aged Care Quality Standards," the report stated.

"(Lyndoch) has not identified these deficits and has not demonstrated clinical oversight of the care being delivered.

"The mix of staff deployed has not delivered safe and quality care and services and effective clinical management has not occurred."

There is a lengthy list of recommendations for improvement, especially in the use of chemical restraints.

"Prior to the administration of chemical restraint ensure that all other strategies have been exhausted," the report said.

"Where strategies being used are not successful, demonstrate that other strategies are considered prior to the use of further medication.

"Ensure records of strategies trialled are specific to the consumer and not generic and demonstrate that clinical staff have a clear understanding of what is working and what is not working.

"Align staff's day-to-day practices with best practice.

"Ensure the governing body has accurate information on the use of chemical and physical restraint and that consent to the use of restraint is recorded and that any restraint reflects best practice."

Other recommendations included:

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