The Irish Patients' Association has called for a Health Information and Quality Authority report on the Lough Corrib Nursing Home near Headford, Co Galway to be passed to the gardaí for review.
IPA spokesman Stephen McMahon said the independent watchdog's ten previous reports on the enterprise should also be referred to the garda authorities and that the HSE and the Department of Health should investigate the results of all 11 inspections.
Speaking to RTÉ News, Mr McMahon described the account of the report as "harrowing".
The nursing home was found to have neither a Person in Charge nor a Deputy Person in Charge when HIQA inspected it last May.
Inspectors also found that it was not possible to ensure that the end of life care wishes of residents were respected because forms which should have contained care plans for their final days were left blank.
Lough Corrib Nursing Home near Headford had a capacity for 26 residents and had 17 older people in its care when an unannounced inspection was carried out by HIQA last May.
It was triggered by the receipt of unsolicited information about governance, staffing arrangements and the care and welfare of residents.
The watchdog's report says that some of the information was validated by inspectors.
It states there was nobody with the rank of Person in Charge of the home, nor was there a deputy to cover this absence.
The sole nurse on duty was tasked with caring for the 17 residents and with supervising care assistants. She prioritised the care of residents and management duties were not fulfilled.
A named Person in Charge was rostered on the rota at the time of inspection even though she had not been present in the centre during the previous two months.
The provider of the service gave a written commitment to the inspectors that a Person in Charge would be appointed within ten days.
Incident forms relating to some residents who had un-witnessed falls contained no evidence of neurological observations being carried out.
And notifications of incidents, for example, a pressure ulcer and an episode of loss of water four months earlier, were not submitted to HIQA as required.
Many residents' records, such as healthcare plans, were incomplete and inspectors found it difficult to track a resident's clinical status and find other information in a timely fashion partly because files contained loose pages.
Late in June, six weeks after the initial inspection, HIQA received further unsolicited information regarding end-of-life care in the same home.
An immediate inspection found that most end-of-life care plans for living residents were blank and it was not possible to ensure that the residents' end-of-life care wishes were respected.
Files of deceased residents were also blank, meaning, the report says, that their end-of-life care was not delivered in line with their preferences.
In one case, where a resident had passed away in the early morning, no priest had been called.
Higher dependency residents and those with cognitive impairments did not have sufficient stimulating events and activities.
Some part-time staff had not been subjected to garda vetting, nor were there references, contracts of employment or full employment histories in respect of them.
No staff training had occurred for six months and only a minority of staff files reviewed showed evidence of mandatory training.
The report states that the provider had informed HIQA by statutory notification of his intention to cease running the Lough Corrib Nursing Home and to open a new centre to be called 'Caiseal Geal Teach Altranais'.
But it adds that at the time of last summer's inspections no application for registration of the new premises has been received by the watchdog.