Chief executive officer Doreen Power said she was also supporting staff to get vaccinated after the Federal Government last week made it mandatory in aged care.

She said Lyndoch was working with Barwon Public Health on the vaccination program in which 95 per cent of residents had been vaccinated.

Ms Power said 57 per cent of staff were fully vaccinated and the rest were in the process of being vaccinated.

An audit by the national peak body Aged Care Quality and Safety Commission in January highlighted the use of an unauthorised chemical restraint on a resident and reported observing staff rushing tasks and walking past a resident calling out for help without stopping to offer assistance. Pain management and wound care were also highlighted in the report.

"We take it seriously," Ms Power said.

Ms Power said under the new regulations there were 44 criteria listed under eight standards, and Lyndoch did not meet three of the criteria in its residential high-care area. Its hostel facilities passed all criteria in what was Lyndoch's first assessment under the new requirements, she said.

She said the report related to the documentation of the care, not the care itself in relation to the chemical restraint issue.

Ms Power said the incident referred to in the report was in its high-care area where they do have high-care dementia residents who could sometimes get quite aggressive.

She said the use of a chemical restraint or restrictive practices wasn't authorised because it hadn't been documented - something that was now a requirement under the new laws which came into effect this year.

Mr Power said under the old laws, it would have been acceptable. "We haven't followed the process that is now required of us," she said.

"Aged care across the nation is reviewing their policies and procedures and how to comply with the new legislation and how we support our staff in providing the high level of care that is required."

Ms Power said that Lyndoch now had an action plan in place, and after the report was released she immediately spoke to the unit managers about how to address the issues and took immediate action.

"As an action coming out of the unannounced visit, I ordered six computers on wheels to assist in ensuring the documentation is done at the time care is provided," she said.

"The focus for Lyndoch is in quality improvement. We acknowledge that we haven't completed all of the actions required to meet the new chemical restraint guidelines, and that also involves the GPs.

"We've taken it onboard, we've reviewed our policies. We're making sure the staff understand the changes.

"I think a lot has been done and we're taking it that it's quality improvement. It's positive. We haven't taken it as a negative.

"It is about our residents and how do we keep them comfortable.

"We want to know what we're not doing well and how we can improve."

Ms Power said they had approached the department's nurses advisor to help them meet the new requirements.

She said 45 per cent of aged-care facilities that had undergone this accreditation process had been given "not mets".

"It's a different system. As an aged-care sector we are working together to improve," Ms Power said.

To address the staff shortage issues identified in the report, Lyndoch has implemented a staff training program.

Ms Power said Lyndoch had also placed 45 ads for personal care workers and nurses over the past 12 months to try and recruit new staff.

The commission is set to revisit Lyndoch this month.

Work has also begun on Lyndoch's new $22 million primary health centre.

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