An Iowa care facility is facing fines totaling $10,000 after mistakenly pronouncing a 66-year-old resident dead and having her transported to a funeral home, where she woke up “gasping for air.”

A new report from the Iowa Department of Inspections and Appeals, released on Feb. 1, 2023 and first reported by CBS affiliate KCCI, details the series of events that led up to the woman being mistakenly pronounced dead. The unidentified resident, who had been at the Glen Oaks Alzheimer’s Special Care Center since Dec. 2021, was moved into hospice care at the facility on Dec. 28, 2022, because of “senile degeneration of the brain.”

While in hospice care, comfort measures were taken. Over the course of several days, staff members recorded occurences of “diminished” lung sounds and minor seizures. On Jan. 3, 2023, the woman was pronounced dead at 6 a.m. after an employee identified as Staff C said that she “did not feel a pulse” and found the “resident was not breathing at that time.”

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The staff member notified a licensed practical nurse. The woman’s family was alerted and a local funeral home was called.

A funeral director arrived shortly after 7:30 a.m., and with the assistance of another nurse, identified as “LPN D,” the resident was placed in a body bag which was zipped shut. The funeral director left the facility shortly afterward. At 8:26 a.m., employees at Ankeny Funeral Home and Crematory unzipped the bag.

Read more: CBS