The Health Information and Quality Authority has found that residents in a centre for people with disabilities in Co Louth were not safe when the facility was inspected by the independent watchdog last January.
The inspectors expressed grave concern about the Bliain Ógra centre where, last year alone, there were 234 reported accidents and incidents relating to the 20 residents.
Bliain Ógra is on the Drumcar campus run by the St John of God Community Services. At the time of last January's inspection, it was home to 20 men with intellectual disabilities.
HIQA's unannounced inspection was triggered by allegations to the watchdog of peer-to-peer abuse and injuries to residents.
Inspectors found there was no permanent person in charge and the person deputising in that role was inadequately supported. This was because the St John of God Services had failed to carry out an audit of safety and quality of care at Bliain Ógra last year.
Today's HIQA report says this meant that the service was not being managed appropriately.
The inspectors say the system of risk management was ineffective and did not keep the residents safe from harm.
They express grave concern that there had been 234 reported accidents and incidents relating to the 20 residents in 2016 alone.
These included peer-to-peer assault, physical and verbal abuse, violence and aggression, exposure to bodily fluids, falls, self injurious behaviour, bruising of unknown causation, absconsions and cases of persons going missing.
HIQA says legal requirements were breached when two serious incidents in September last year which required a resident to seek medical interventions were not reported to HIQA.
Following previous negative reports, the St John of God Services had assured HIQA that it would begin moving residents to less crowded accommodation by last September but no residents had transitioned to the community by the time of last January's inspection.
Of the ten headings assessed in January's inspection, eight were found to be non-compliant in a major way with the State's regulations. These included residents' rights, premises, health, safety and risk management, safeguarding, healthcare needs, governance and management, social care needs and workforce.
Moderate non-compliances were found in health care needs and documentation. No standard inspected complied with regulations.
While inspectors found that some progress had been made to support residents to move to more suitable accommodation, sufficient systems were not in place to implement the overall plan in accordance with the time frames and undertakings given to HIQA.
An action plan, which is published at the end of today's report, sets out what the St John of God Services or person in charge must do to ensure compliance with the relevant regulations.
Similar plans are published in the three previous inspection reports on Bliain Ógra.