The Aged Care Commissioner has found Oceania Care company Limited breached the Health and Disability Code in its care of a man in his 80s

He had Parkinson's disease, heart failure, poor hearing, partial blindness and recurring mini strokes.

He fell in on his first night in respite care at Victoria Place Rest home.

Commissioner Carolyn Cooper found it wasn't properly documented and he wasn't checked.

After two days his family urged staff to take him to hospital, where it was found he'd had more strokes, and he died two days later.

Cooper's ordered staff to make several changes - and apologise to his family.