Facility that sent live resident to funeral home in a body bag is fined $10,000

Woman was left ‘gasping for air’ inside body bag

By: - February 1, 2023 4:37 pm

Glen Oaks Alzheimer’s Special Care Center in Urbandale, where a live resident was sent to a funeral home in a body bag. (Photo via Google Earth)

An Iowa care facility that mistakenly sent a live resident to the funeral home in a body bag has been fined $10,000 by the state.

According to state inspectors, a female resident of the Glen Oaks Alzheimer’s Special Care Center in Urbandale was in declining health and receiving hospice care in late December 2022 and early January of this year.

At about 6 a.m. on Jan. 3, a worker at the home – state records do not indicate whether she was an aide, a licensed nurse or some other type of employee – checked on the resident and couldn’t detect a pulse or signs of breathing. The resident’s eyes were open, the worker later told inspectors, but she “felt the resident had passed away” and so she notified a nurse that was on duty, according to the inspectors’ report.

That nurse later told inspectors the woman’s mouth and eyes were open, but the eyes appeared to be fixed, and there were no breath sounds or pulse that could be detected even with a stethoscope. Believing the resident was dead, the nurse notified the resident’s family, and an on-call hospice nurse notified a funeral home.

At 7:38 a.m., a funeral home director arrived at Glen Oaks and, with the assistance of a facility nurse, they placed the woman on a gurney inside a cloth body bag and then zipped the bag shut.

About one hour later, at 8:26 a.m., the funeral director unzipped the bag at the funeral home and noticed the woman’s chest was moving and she was “gasping for air.” EMTs were summoned to the funeral home, and they recorded the resident’s blood pressure, oxygen levels and pulse. At the time, the woman’s eyes remained fixed in place, she was nonverbal and had no motor response, according to state inspectors.

The woman was then taken by ambulance to a hospital emergency room where it was noted that her breathing was shallow. She was then returned to the Glen Oaks facility for continued hospice care. Two days later, the woman died with her family at her side.


State records indicate the woman had been admitted to Glen Oaks a year before, in December 2021, with a diagnosis of end-stage, early onset dementia, anxiety and depression. The resident was provided hospice care beginning Dec. 28, 2022, and had a do-not-resuscitate order in place.

The facility was cited by the state for failing to treat residents with dignity and failing to provide appropriate care and services for residents at the end of life.

Glen Oaks is a not a skilled nursing facility that is subject to the same federal regulations and oversight as a nursing home. It is a state-licensed residential care facility that provides board, personal assistance and other essential daily living activities.

According to the Iowa Department of Inspections and Appeals, people living in an Iowa residential care facility are unable to sufficiently or properly care for themselves but “do not require the services of a registered or licensed practical nurse except for emergencies.”


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Clark Kauffman
Clark Kauffman

Deputy Editor Clark Kauffman has worked during the past 30 years as both an investigative reporter and editorial writer at two of Iowa’s largest newspapers, the Des Moines Register and the Quad-City Times. He has won numerous state and national awards for reporting and editorial writing.