An 86-year-old care home resident who weighed just 4st when she died was unlawfully killed, an inquest finds.
Ivy Atkin died of pneumonia in November 2012 after being transferred from Autumn Grange home in Nottingham.
Yousaf Khan, the owner of the home, was jailed in February for gross negligence manslaughter over her death.
Health inspectors were criticised by the Nottinghamshire Assistant Coroner for "missing opportunities" to uncover conditions at the home.
Assistant coroner Stephanie Haskey said there had been a "degree of failure" by the Care Quality Commission (CQC).
In a statement, Sue Howard, CQC's deputy chief inspector for adult social care, said: "The level of care at Autumn Grange was unacceptable and our inspectors were truly shocked by what they found.
"We took urgent action in November 2012 to ensure the safety and welfare of people using the service, with our partner agencies, and cancelled the home's registration, which closed the home."
Ms Haskey said in the light of concerns raised about conditions at the home, the inspection "should have been more rigorous" and inspectors failed to "be proactive".
In February 2012, the home had a warning about infection control and cleanliness, the inquest was told.
Six months later, a staff member said there was no Criminal Records Bureau check on her while she worked there.
Then in October, there was a fight between two residents where one was injured and taken to hospital.
Mrs Atkin and the other residents were moved out on 4 November after a snap inspection, but she died on 22 November.
The inquest also heard Mrs Atkin died from pneumonia as a result of debilitation and low body mass index (BMI), contributed to by dementia.
Her BMI was just 10.7, while the healthy weight range is between 18.5 and 24.9.
On Wednesday, inspector Lesley White told the inquest that during her inspection weeks before Mrs Atkin died, residents were "sat in dirty clothes, in their own urine".
However, Mrs White said she had not "missed anything" in an inspection in September and that a home could go "downhill quickly".
Ms Howard added: "We acknowledge the coroner's comments about aspects of our response to the level of poor care being provided at Autumn Grange during September and October of 2012.
"Since this time, as was recognised by the coroner, CQC's approach to monitoring and inspecting adult social care has changed and is now far more robust.
"We have more inspectors with greater expertise and we are working more closely with our local partners to respond to concerns."
After the inquest Nottingham City Council said they expected very high standards from care homes and if anyone was concerned about care their complaints "would be looked into as a matter of urgency".