The Health Information and Quality Authority has criticised restraint methods used on residents in a centre for people with intellectual disabilities with complex behaviour management issues.
HIQA says the Redwood Extended Care Facility in Stamullen, Co Meath has taken actions in response to its concerns.
However, the owners have said HIQA's report exposes the State and the facility to what they call serious legal risk.
Minister of State Kathleen Lynch said she has "major concerns" of HIQA's criticism and said she would not rule out the appointment of an independent confidential recipient to deal with complaints of abuse and ill treatment in care homes.
However, she said at the moment anyone with a complaint about the treatment of any person in a care home can make a report to the HSE, HIQA or the gardaí.
The HIQA report on the facility is based on two inspections last September lasting, in total, 13 hours.
The centre is home to 34 people aged 18 to 69 with complex and high support needs, particularly in relation to behaviour management issues.
This inspection focused on the management of restrictive measures and restraint and the protection of residents' civil rights.
It was prompted by notifications by the facility of 772 incidents of physical restraint within an 11-month period.
One resident accounted for 184 incidents of physical restraint, another for 87.
Recurrent and lengthy durations of physical interventions up to two and a half hours were reported.
It concentrated on the five residents who were most at risk and most heavily restricted.
Inspectors found that residents were not routinely assessed or reviewed by a doctor following lengthy episodes of challenging behaviour and prolonged physical restraint.
Inspectors read a report where the staff response to a medical emergency was not timely.
It stated that during a physical restraint incident last December a resident had struggled to breathe and appeared to turn purple and to have insufficient oxygen.
However, this resident was not reviewed by a doctor until the following day.
After further assessments, the medical note included the quotes "banged back of head" and "staff concerned of struggle to breathe".
However, HIQA says this detail was not recorded in the staff's incident form and was omitted from the incident review document.
Furthermore, HIQA says clinical observations such as the resident's respiration and pulse rate, blood pressure and oxygen saturation levels were not recorded to illustrate adequate physiological and psychological assessment and monitoring.
It says that, in general, while post-physical-restriction reviews were carried out by staff, there was little evidence of them leading to effective changes.
The reviews appeared to be self-appraisals.
Inspectors were not assured that practices and restrictive procedure arrangements were least restrictive and for the shortest duration necessary to meet residents' needs.
Nor were they assured that the very restrictive measures and significant levels of physical interventions had a therapeutic value.
Facility has concerns about report's accuracy
In a statement, Redwood Extended Care Facility said: "This is a HIQA document and questions regarding the content of the document have to be addressed to HIQA.
"Redwood Extended Care Facility have serious concerns regarding about the accuracy of the content of HIQA's report and are concerned by the investigative process and the means by which the findings set out have been brought into the public domain.
"Given the legal concerns raised the owners of the redwood facility have no further comment."
