In early January,Winning Exchange an Alzheimer's care facility in Iowa pronounced one of its residents dead. But when funeral home staff unzipped her body bag, she was in fact alive — and gasping for air, according to a citation from the Iowa Department of Inspections and Appeals.

The 66-year-old woman, who was't named in the report, was admitted to the Glen Oaks Alzheimer's Special Care Center in Urbandale, Iowa, in December 2021. She had diagnoses including end stage early-onset dementia, anxiety and depression, according to the document.

She went into hospice care at Glen Oaks on Dec. 28, 2022, with "senile degeneration of the brain" and was administered lorazepam and morphine for comfort, the report says.

At 6 a.m. on Jan. 3, a nurse was unable to find the resident's pulse, and shedidn't appear to be breathing, according to the report. The nurse notified the family and hospice nurse, who in turn notified the funeral home. Another nurse and the funeral director, who arrived to pick up the patient around 7:38 a.m., also reported no signs of life.

About 45 minutes later, funeral home staff unzipped the bag and found the patient's "chest moving and she gasped for air. The funeral home then called 911 and hospice," the document says.

Emergency responders found the womanbreathing but unresponsive. The patient was transferred to the emergency room for further evaluation, then returned to Glen Oaks for continued hospice care.

The patient died early in the morning on Jan. 5 "with hospice and her family at her side," the document says.

Based on interviews and records, the report found that Glen Oaks"failed to provide adequate direction to ensure appropriate cares and services were provided" and "failed to ensure residents received dignified treatment and care at end of life." The facility is now facing a $10,000 fine.

Glen Oaks did not immediately respond to an NPR request for comment.