A centre for women with intellectual disabilities which had its registration cancelled by the Health Information and Quality Authority last March was still seriously in breach of regulations three weeks later despite its transfer to the Health Service Executive.
Among the failings outlined in today's report by the watchdog were gaps in internal fire doors which would allow smoke to spread through the building.
St Vincent's Centre in Cork city, which was run by the Sisters of Charity until March this year, was home to 39 women with intellectual disabilities when HIQA carried out an unannounced inspection late in April.
It had the capacity to accommodate 60 residents and many had been living there for a long time.
The inspection monitored compliance with regulations under five headings a month after the HSE took over the running of the facility after its registration was cancelled due to major non-compliance with regulations in the provision of social and healthcare, fire safety, resourcing and governance and management.
But all five areas inspected in April revealed continuing major non-compliance.
For example, there had been a fire in the smoking room when the HSE was in charge which resulted in the emergency services being summoned.
They highlighted a number of significant issues that needed to be the centre's management to ensure that a similar incident did not recur.
But the location of and the use of the smoking room had not been addressed.
A review had not been completed of the telephone coverage throughout the building in the event of an emergency.
The fire doors on the corridors had large gaps which would permit smoke to get through.
More generally, the service could not meet the assessed needs of all residents, particularly residents with dementia.
Residents with co-complex care needs had not yet been assessed by a multidisciplinary team.
Today's report says that due to the seriousness of April's findings and concerns regarding the care and safety of the residents, matters were escalated on the day of the inspection to the office of HIQA's chief inspector.
An instruction was issued to convene a meeting five days later with the HSE to seek assurances that residents were safe.