According to the report, the worker was transferring the elderly woman on her own to her room when she suffered the fall.
The woman, then in her late 70s, was left on the floor for seven minutes, completely alone, while the assistant went to seek help.
"While the woman was on the floor, her dress remained up past her knees, and she was not provided with a pillow, a blanket, or any other physical means of comfort until the registered nurse arrived," the report stated.
Chief executive of Colwyn's owner Heritage Lifecare, Norah Barlow, said they regret the "inadequacies" in care of the resident.
"Heritage has no tolerance for any failure by staff to follow our culture of respect and empathy. The lack of empathy shown by the caregiver in this instance was unacceptable to us," she said.
The woman's care plan noted that she was a high falls risk, unsteady on her feet and required two-person assistance when mobilising.
On the evening in question in 2019, staffing shortages resulted in only two healthcare assistants providing care to 20 residents in the women's wing of the rest home, while just two registered nurses were tending to 70 residents at the rest home in total.
Wall said the rest home has "an obligation to ensure that their care staff has sufficient training, and that the staffing levels are adequate at all times, in order to support the staff in their roles."
"It is apparent that there were shortfalls in both of these areas, and that this had a negative impact on the care provided," Wall said.
The investigation found the healthcare assistant in question had not undergone recent training on falls management or dementia care.
Colwyn House, a high dependency rest home, couldn't provide any evidence of the assistant's dementia-specific training during her employment at the home.
The report said Colwyn House failed to seek a timely GP review once the video of the footage of the woman's fall was viewed.
Wall was critical of the poor judgement made by the healthcare assistant deciding to transfer the woman on her own and found the assistant failed to respect the woman's dignity after the fall.
The report also found the healthcare assistant showed no sense of urgency or concern for the woman's safety or wellbeing following the fall, and had little empathy.
The report said the assistant didn't hold the woman's hand or maintain any physical contact.
The healthcare assistant had since resigned, citing ongoing staffing issues.
"I decided to leave due to the continued level of short staffing, the unreasonable expectations on staff and because staff training was not a priority," she said.
The family said they consider the care provided following their relative's fall to be insufficient.
"None of [the other staff] came to help. This was due to lack of staffing within the rest home making it extremely unsafe for the [residents] and also unsafe for the staff," the family said.
The findings have also shown Colwyn House Lifecare is subject to an ongoing enquiry by the Hawke's Bay District Health Board.
Wall said the rest home should report back to the Health and Disability Commissioner on the findings from the DHB inquiry, a surveillance audit and on their steps taken to address staff shortages.
She also recommended the home review its staff training records, falls policy, and apologise to the woman and her family.
Barlow said the complaint came about after Heritage Lifecare became aware of the situation and it then "proactively advised the family."
She said the company had written an apology to the victim's family and implemented the report's recommendations.
The New Zealand Aged Care Association could not be reached for comment.
