Employees at Glen Oaks Alzheimer’s Special Care Center in Iowa mistakenly reported a 66-year-old woman dead and transferred her to a funeral home in a body bag, according to a report made from the Iowa Department of Inspections and Appeals on Wednesday (Feb. 1).

According to the report, the resident, who was suffering from dementia, anxiety and depression; began living in the facility in December 2021. She was transferred into hospice care on Dec. 28, 2022 because of “senile degeneration of the brain.”

A staff member reported that she couldn’t feel the woman’s pulse, so she alerted a nurse. Based on the nurse’s notes, she “appeared calm and comfortable,” however, stopped coming out of her room for meals and refused food. Hospice staff claimed they later noticed a decline in temperature and that “she did not open her eyes and did not speak or respond” and began to suffer multiple “minor” seizures. The nurse ended up making the death declaration. Iowa law allows nurses and physicians’ assistants, in addition to doctors, to declare a patient dead.

The funeral director also reported no signs of life when the elderly woman arrived to the care center. He “placed [the woman’s] body on the gurney inside a cloth bag and zipped it shut,” the report read. When she arrived at the funeral home, a staff unzipped the bag and saw that her chest was moving, then called 911.

When emergency medical services arrived at the funeral home, the woman had “no eye movement, no verbal or vocal response, and no motor response.” She was returned to the hospice, where she died two days later on Jan. 5, the report noted.

Glen Oaks Alzheimer’s Special Care Center is being fined $10,000 for violating the resident’s dignity and for failing to “assume the responsibility for the overall operation of the residential care facility.”