Residents at a centre for people with disabilities in Louth were locked into a unit, alone, because of a shortage of staff on duty.
That's according to two new HIQA reports into conditions at the centre following two unannounced visits earlier this year.
The two reports follow unannounced inspections at the facility - which caters for men with intellectual disabilities based in Co Louth - in February and April.
The second visit also uncovered an incident of alleged physical assault of a resident by a non-permanent staff member, which "was not managed and investigated in a timely manner in order to safeguard all residents."
HIQA hasn't identified the centre, but says it's run by St John of God - and also says that HIQA's inspectors would have offered their feedback on the first visit, before making the second one.
However it said the action plan compiled by the centre after the first visit, to deal with HIQA's findings, was later rejected as the actions and timeframes did not deal with the risks.
Both reports found significant examples of staff shortages. For example in one case, a resident who had the money to buy things to enhance his lifestyle, wasn't able to access his funds - because he needed the signatures of staff who weren't available.
In one case residents were being taken to mass - but because there weren't enough staff to push a wheelchair user, he was left behind, while still wearing his outdoor coat.
On the second visit it was found that there were "ineffective leadership, governance and management arrangements" which put residents at an unacceptable risk.
It found three occasions, in a two-week period, where a staff shortage meant residents were locked into a unit while a staff nurse visited the other unit to administer medicines.
The report also said there was no bath available and showers were inadequate - while residents had to sit sideways to use the toilet because of the cramped conditions.