The Health Information and Quality Authority has found that a HSE-run respite service for people with disabilities in Co Donegal punished a resident who complained of abuse by changing his or her respite arrangements.
The watchdog found that Drumboe Respite House failed to report serious allegations of abuse or to investigate them appropriately.
HIQA has published 20 reports on residential services for people with disabilities.
The centre near Stranorlar comprises two houses, but one was not operating at the time of last April's inspection.
The other provided day and overnight respite services to a total of up to 61 adults and children.
Seven residents were accommodated at any one time and the Health Service Executive had applied to increase that by one, a request HIQA turned down.
Inspectors identified significant risks to the safety and welfare of residents and found that serious allegations of abuse had not been appropriately reported to management or, when they were reported, had not been properly investigated in accordance with national safeguarding policies or procedures.
The inspectors identified one instance of a resident reporting an allegation of abuse only to be adversely affected by having his or her respite services changed.
Other "serious failings" were discovered in how the centre was run and these compromised residents' quality and safety of care.
There was limited evidence of the HSE carrying out ongoing risk management audits at its centre.
HIQA also found that the HSE had failed to undertake six-monthly unannounced visits or an annual review.
Gaps were identified in the mandatory training provided to staff in regards to the management of behaviour that challenges and the protection of vulnerable adults.
Major non-compliances were identified in 11 of the 18 outcomes inspected in relation to residents' rights, dignity and consultation, communication, family and personal relationships, admissions and contracts for the provision of services, social care delivery, safe and suitable premises, health and safety and risk management, safeguarding and safety, notifications of incidents, governance, management and staffing.
During the inspection, the HSE was required to take immediate action in response to the serious safeguarding and risk issues identified and three monthly reviews were ordered.
Responding to the report, the HSE said that since April's inspection of the facility, all staff have been trained in safeguarding and protection awareness.
In a statement, the HSE said single-bedroom occupancy has been implemented in the centre.
It said weekly residents meetings have commenced, as has a consumer forum which involves residents, families, representatives and staff to support a person-centred community model.
It also highlights an ongoing programme of staff-training on managing behaviours of concern.
The HSE also said that a clearly defined management structure has been put in place in the centre that identifies lines of authority and accountability, specific roles, and which also details responsibilities for all areas of service provision and says that managers have received training in managing risk.