A residential centre for people with learning disabilities in Cork city was told by Health Information and Quality Authority to investigate an allegation by inspectors that a staff member had verbally abused a resident.
The watchdog also criticised the COPE Foundation for sometimes having only one staff member caring for up to six residents in a house when a colleague called in sick.
Ard Dara on Cork's northside was home to 36 adult residents with intellectual disabilities when HIQA made an unannounced two-day inspection last June.
By the end of the first day, inspectors had instructed the owners, the non-profit COPE Foundation, to replace worn and bald tyres on two of the resident transport buses.
They also ordered the repair of the centre's only fit-for-purpose suction machine to enable staff to provide emergency help to residents with a documented high risk of choking.
An allegation by inspectors that a staff member had verbally abused a resident sparked an internal investigation.
Inspectors found that staff shortages meant that sometimes, when a colleague called in sick, only one staff member had to care for five or six residents in a house.
The centre's kitchens continued to be dirty, despite criticism regarding the same issue during an inspection two months earlier.
Altogether 34 of the 35 actions specified in the improvement notice issued after that inspection had not adequately progressed.
HIQA warned COPE that, due to the consistent and serious failings identified during three recent inspections, it would further escalate its procedures regarding the centre's regulation.
COPE has produced an action plan, which is published in today's report.
A further HIQA inspection has taken place since June and the watchdog says a report will be published "in due course".
COPE says 'significant improvements' made
The foundation has said "significant improvements" have been made to the centre since HIQA made its "wholly unacceptable" findings.
In a statement, COPE said "the key issues identified in the report have already been addressed."
Speaking to RTÉ News, a spokesperson said three residents that HIQA identified as at risk in Ard Dara have been moved to what was called more suitable accommodation in the COPE network.
The foundation says a further unannounced HIQA inspection of the centre on 1 September demonstrated the significant progress made and the organisation looks forward to the publication of the report.
The statement continues: "With the support of the HSE, additional resources have been made available and directed towards the solution of shortcomings in the operation of this centre.
"As a result, Cope Foundation has made managerial and staff changes and sourced external supports to expedite the improvements which both [it] and HIQA sought to achieve for the people we support in this centre."
The spokesperson added that three residents whose inappropriate placements were highlighted by the watchdog have been relocated in consultation with the residents and their families.
The foundation also says it is in continuing dialogue with the families of Ard Dara's residents about recent HIQA inspections and its efforts to address the issues raised.
