A County Down woman has said nursing home staff did not tell her that her mother had died when she arrived to visit.
The incident happened at Cherry Tree House private nursing home in Carrickfergus in April 2011.
A confidential review into the incident said there were gaps in how the home had managed contact with relatives.
It came a day after a whistle-blower said she had raised concerns about standards in the home in 2005.
Staff from Cherry Tree Nursing Home in the County Antrim town telephoned Elizabeth Calvert to say her 88-year-old mother, Olive Heylings, was unwell.
According to Mrs Calvert, when she arrived at the home a short time later she looked for her mother in her bedroom and the dining room but could not find her.
She said a member of staff then asked if she wanted to see her mother and that, at that point, she was brought to another resident's bedroom.
She said: "We were shown in the bedroom and my mum was lying on the bed and my husband turned round and said: 'Oh, God she's dead.'
"That's when I went mad, I was so tearful. She was just lying in bed, no covers round her and her mouth lying open. It was very distressful."
A confidential report into the incident by the northern health trust has been seen by the BBC.
The review team also referred to a document, issued in 2012, that detailed standards including how to break bad news to relatives.
In a statement, the northern trust said it had investigated the case and met Mrs Calvert to "discuss the issues raised and offer any required support".
It added: "The trust apologies for any distress caused to Mrs Calvert."
The RQIA (Regulation and Quality Improvement Authority) confirmed that it had been asked by the Department of Health to conduct a review of the responses of health and social care organisations to allegations made concerning Cherry Tree House.
In a statement, Cherry Tree House said: "Cherry Tree House nursing and residential home relies on RQIA to ensure we meet best practice in all areas of our work, and where shortcomings have been identified these have promptly been addressed to the satisfaction of our regulators.
"We appreciate the steps taken by the Department of Health in response to the recent whistle-blower's allegations and the appointment of an independent panel to investigate both the anonymous and attributable claims made, and we are committed to fully co-operating with the panel in its endeavours.
"In the meantime we would wish to emphasise that Cherry Tree House nursing and residential home, as with all other similar settings regulated by RQIA, continues to provide appropriate, safe and effective care for all its residents."
On Monday, it emerged that the health minister had ordered a review of the nursing home eight years after a whistle-blower said she first made allegations of patient neglect and poor practice.
The former care assistant described the standard of care at Cherry Tree House nursing home as sometimes "appalling".
She alleged patients often were not fed if they were unable to feed themselves.
None of the whistle-blower's criticisms are connected to anyone currently working in the Carrickfergus home.
The BBC has also been contacted by relatives of nursing home residents who said their loved one had received an excellent standard of care.