Elderly people were left at risk in a Wakefield care home after their medicine records were muddled.
Patients at The Sycamores, on Norton Road, regularly missed doses of their prescribed drugs, a report by the Care Quality Commission (CQC) said.
The home has been placed in special measures after the regulator declared that the 39 people living there were not safe.
The CQC said concerns about poor medicine management at the home had been raised with them before it visited in August this year.
Those concerns were vindicated by its findings as inspectors ruled that medication was "not managed safely".
The report said: "Staff did not always follow the prescriber's instruction. For example, one person was prescribed medicines to treat constipation which should be administered once a day.
"Staff were not following this instruction because we saw the person only received the medicine four out of the last nine days.
"Another person was prescribed a medicine to treat constipation which should also be administered once a day. They had not received the medicine in the last nine days."
Inspectors also criticised the home for a lack of bathing facilities, and said patients told them they "did not receive regular baths and showers".
Despite being graded inadequate on three out of five criteria, care staff and managers were praised for several aspects of the service.
The report added: "We observed staff were kind and caring in their approach. They knew people well and chatted to people about their family members.
"Staff attended promptly to people if they heard them calling out or observed
them needing attention.
"Staff's caring and committed approach was a key strength of the service, in spite of the shortfalls in all of the other domains and the weaknesses in the leadership and management of the home."
The home must put in place urgent measures to improve or face the risk of being closed down.
The venue's owners, Bridlington-based Burlington Care, did not respond to a request for comment.