An aged care facility tied a resident to a chair for over 11 hours last year.
The chief ombudsman has released a report into six facilities after inspections last year.
It found conditions were generally good but chief ombudsman Peter Boshier said one facility repeatedly physically restrained two people.
One had been tied to a chair from 9.30am until midnight.
Boshier said restraints were part of the two residents' care plans, but he was concerned they only had a few minutes off before being restrained again.
The facility has stopped the use of restraint for one resident and reduced it for the other.
The report covered six facilities across Hastings, Whanganui, Palmerston North and Nelson.