Peter Joseph Guy died in hospital on April 23, 2022 while being treated for injuries suffered in an unwitnessed fall 22 days earlier at Freemasons Home in Hobart.
A coronial report published on Friday found the home did not appear to have used bed alarms or any other sensory or mobility alarms for Mr Guy despite repeated falls.
"A bed alarm would not have prevented Mr Guy's fall on (April 1) but it would have led to a quicker response," coroner Simon Cooper wrote.
"Moreover there is no evidence of bed rails being used by the nursing home.
"Bed rails would almost certainly have prevented the fall."
An audit conducted not long before Mr Guy's death found the home didn't meet seven of eight standards, Mr Cooper wrote.
The coroner asked Freemasons Home for information about Mr Guy's fall history.
Mr Cooper said Masonic Care Tasmania, then-operator of the home, only provided details about falls for three months before April 1.
He said Masonic Care Tasmania omitted information in relation to a fall in 2022 in which Mr Guy suffered a compression fracture of his spine.
"It is apparent that the response was deliberate. Whether it was deliberately misleading is unclear," he wrote.
Mr Cooper said Respect Group, which assumed management of Masonic Care Tasmania in December 2022, said it was disappointed Masonic Care Tasmania's response appeared misleading and omitted certain facts.
In a statement to AAP, Respect Group CEO Jason Binder said the organisation had confidence in its systems and staff.
"All new homes joining Respect undergo a transformation to our organisation's policies and processes," he said.
"(This) includes best-practice falls procedures ... this transformation occurred at all former Masonic Care Tasmania homes including Freemasons Home."
Mr Cooper described Mr Guy's care at the home as substandard and Masonic Care Tasmania's level of co-operation during his investigation as poor.
He noted there was a legal, and perhaps moral, obligation for residential aged care facilities to co-operate fully with any coronial investigation.
Mr Guy had lived at the home since September 2019, when he was admitted because of deteriorating physical and mental health.
