A care facility in Iowa is facing penalties of $10,000 after a shocking event in which a 66-year-old resident was wrongly declared dead and taken to a funeral home, only to wake up later “gasping for air.”

A report from the Iowa Department of Inspections and Appeals, dated February 1, 2023 and initially reported by CBS affiliate KCCI, describes the series of events that led to the unfortunate misdiagnosis.

The resident, whose identity has not been disclosed, was a resident at the Glen Oaks Alzheimer’s Special Care Center since December 2021 and was transferred to hospice care at the facility on December 28, 2022, due to “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.” 

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. 

They “observed (the resident’s) chest moving and she gasped for air,” the report states. 

The funeral home then called 911 and the care facility. When EMS responded, they were able to record a pulse and breathing, but there was no eye movement and no verbal response. 

That same day, the resident was returned to the care facility. She passed away early in the morning of Jan. 5, with her family at her side, the report said. 

“We have been in close communication with the family of the resident, and we just completed an investigation by the Department of Inspections and Appeals regarding the matter,” Lisa Eastman, the facility’s executive director, told CBS News. “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.”

The facility faces two state violations from the DIA, which could result in a $10,000 fine.