The deputy Health and Disability Commissioner says a rest home in Whakatane gave inappropriate and inadequate care to an elderly man who died after staying 17 days.
Theo Baker criticised the treatment provided by Sheaffs rest home, its manager and a registered nurse.
The 77-year-old man went to Sheaffs rest home after being treated in hospital for a chest infection and dehydration in 2011.
He was also suffering depression.
The man's health deteriorated over the next 17 days, and he ate little.
However Ms Baker says the home didn't take proper action until his family asked that he be sent to hospital.
The man arrived frail and dehydrated and had suffered a heart attack, and he died a few days later.
Ms Baker found the rest home, the facility manager and a registered nurse breached the Code of Consumers' Rights.
The rest home says the man refused to eat despite the best efforts of staff and his wife.
However, it accepts it failed to follow a care plan and is making changes recommended by the commission.
The deputy commissioner has forwarded her report to the Ministry of Health, Bay of Plenty DHB, the Aged Care Association and the Nursing Council.