The Ministry of Health had twice found the management of medicines was inadequate at an Otaki rest home, before a resident there died from being given the wrong drugs.
Margaret Borgen, a resident at the Ocean View Rest Home, died in Palmerston North Hospital in May last year.
Ms Borgen, who was 96, was given blood-pressure medication prescribed to another resident.
Hastings coroner Christopher Devonport said staff at the rest home did not follow correct procedures.
A Health Ministry audit in March last year concluded the rest home needed to improve its medicine management and documentation processes.
The ministry said another audit of the rest home in March this year found improvements had been made, but more needed to be done.
It said its full report on the latest audit will be on its website by the end of the month.