The Health and Disability Commissioner ruled the on-call nurse should have been notified due to the woman's shakiness, stiffness and the fact her legs would suddenly collapse under her.
The woman's daughter did not wish to be identified out of respect for the family's privacy but told the Herald they had no idea it had happened until the next morning when the woman was finally taken to hospital.
Even then the first call did not go to the woman's enduring power of attorney, but an in-law who was reassured on the phone that while the woman was in hospital she was fine.
An ambulance officer told the family something had gone seriously wrong, and that they should be asking questions about why the woman was not hospitalised earlier.
The family filed a complaint with the HDC but decided against legal action because "it would not bring back our mother".
It was not about assigning blame, the daughter said.
"It was about the standards across the facility as a whole improving."
She has written a letter to the rest home outlining her disappointment.
"As you will no doubt be aware the ruling from the commissioner found that your staff failed to provide adequate care to our mother," the letter read.
"In fact a number of failings were found by the investigation.
"We as a family were asked what we wanted out of the complaint and investigation and what action we wanted to take ... what we really wanted were measures put in place to improve the standard of care and prevent this happening to anyone else.
"Therefore I'm sure you can appreciate we are upset to hear of recent allegations and feel that unless we speak out we cannot be sure such abuse won't continue."
Heritage Lifecare, the parent company of Palms Lifecare, executive chairman David Renwick said the incident had occurred under a different ownership.
Renwick said they had taken on board the recommendations after the incident and had retrained staff about the fall protocols.
They had also "dramatically" increased the number of staff and level of experience present on the night shift, he said.
"There was only an enrolled nurse on duty, now a registered nurse is permanently on duty."
Palms Lifecare would be releasing the findings of both an in-house and an independent investigation regarding the current claims of neglect.