A bizarre incident involving a continuing care facility has drawn the scrutiny of state regulators in Iowa after a woman was declared dead and transported in a body bag to a funeral home, only to be discovered breathing.

Healthcare workers at Glen Oaks Alzheimer’s Special Care Center in Urbandale, Iowa, claimed that a 66-year-old woman in their care had stopped breathing and had no pulse on January 3. Multiple staff members concurred, and the woman was declared dead about 90 minutes after a nurse practitioner first noticed, according to NBC 5 DFW.

The woman was reportedly inspected by a funeral home employee before being zipped up in a body bag and transported to Ankeny Funeral Home & Crematory. Upon her arrival, the funeral director unzipped the bag and found that the woman was “gasping for air,” the Iowa Capital Dispatch reported.

An ambulance transported the woman to a hospital, where she was examined before being taken back to Glen Oaks. She died at the facility a few days later.

The Iowa Department of Inspections & Appeals fined Glen Oaks $10,000 over the incident, stating, “Based on interview and record review, the licensee failed to provide adequate direction to ensure appropriate [care] and services were provided,” per CNN.

The Dallas Express reached out to Glen Oaks to ask about the penalty it received but the organization’s executive director, Lisa Eastman, was not immediately available for comment.

In an earlier statement to CNN, Eastman said:

“We care deeply for our residents and remain fully committed to supporting their end-of-life care. All employees undergo regular training so they can best support end-of-life care and the death of our residents.”

According to the Iowa Capital Dispatch, the woman was admitted to Glen Oaks in 2021, suffering from end-stage, early-onset dementia. She had a do-not-resuscitate order in place.

It is unclear whether the healthcare workers involved in the incident are still employed at the facility, but such operations “do not require the services of a registered or licensed practical nurse except for emergencies,” according to the Iowa Department of Inspections & Appeals.