The Health Information and Quality Authority has said staffing levels must be urgently reviewed at a State-run residential centre for people with learning disabilities in Co Sligo.
Reports by the watchdog found major non-compliance in 19 of the 23 areas of activity inspected at Cregg House, which is run by the Health Service Executive.
Cregg House, near Ballincar, Co Sligo, was taken over from an order of nuns by the HSE around 18 months ago following a dispute over funding.
It is home to 108 residents with intellectual disabilities, some of them children.
The first of the inspections was carried out last December in a unit housing eight residents aged in their 30s and 40s.
Incidents of challenging behaviour had left two residents with lacerations and a HIQA inspector injured.
All exits were locked and there was no key or push button nearby to facilitate exit in the event of a fire.
HIQA found staff were constantly in reactive mode and ordered an urgent review of staffing levels.
That call was echoed following last January's inspection of two units housing 14 residents.
Several had not left the Cregg House campus for several months.
There were insufficient plans for managing residents' behaviour and one resident had received chemical restraint on 13 occasions in the previous few months.
The HSE has said it accepts and welcomes all of the findings and recommendations in the reports on HSE Cregg Services.
In a statement, the executive said it has been working to implement all of the recommendations, but noted there were a number of positives highlighted in the reports.
The HSE said it has made a number of "major improvements" in the services for residents including appointing a Director of Services, additional frontline staff and introducing a wider range of meaningful social activities for residents.
The HSE said that it has increased staffing levels at Cregg house by 22% since the HIQA inspections.
A spokesman said that 22 extra personnel were employed in providing direct services to the 107 residents in the facility.
He said the HIQA reports emphasised that staff were knowledgeable about their clients and respectful and caring.
He said an action plan is being developed to address all areas of non-compliance discovered by HIQA.
The head of Inclusion Ireland has said it is a shocking report into how people with disabilities are supported within HSE facilities and other facilities.
Paddy Connolly told RTÉ News At One that it's critical the HSE act at local level and the Government invest in upgrading centres and in moving people into the community.
He said the HSE system of care and support is failing hundreds of people and that medications are being used to subdued patients rather than providing an environment with meaningful activities, saying "it is not a meaningful life".
