A hospice facility in Iowa has been fined $10,000 after it mistakenly presumed a woman dead hours before she was discovered gasping for air inside a body bag at a funeral home, officials said.

A nurse at Glen Oaks Alzheimer’s Special Care Center in Urbandale determined that the 66-year-old woman had died on Jan. 3, and the resident was transferred to a funeral home, the Iowa Department of Inspections and Appeals said in a report issued Wednesday.

The woman, who has not been publicly identified, was admitted to hospice care Dec. 28 because of “senile degeneration of the brain,” the report says.

At 6 a.m. Jan. 3, a nurse checked on the patient and found no signs of life, according to the report.

Her “mouth was open, her eyes were fixed, and there were no breath sounds,” the report says, adding that a nurse was unable to locate the woman’s pulse using her stethoscope.

The nurse put her hand on the woman’s abdomen and “noted no movement,” the report says. The nurse presumed the resident had died and notified a family member and the on-call hospice nurse, according to the report.

“Hospice agreed to call the funeral home and did so,” it says.

Nearly an hour and 40 minutes later, a funeral director placed the woman’s body on a gurney “inside a cloth bag and zipped it shut,” the report says. The director left with the woman about 10 minutes later, the report says. Shortly before 8:30 a.m., staff members at the funeral home discovered that the woman was still alive, the report says.

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“Funeral home staff unzipped the bag and observed Resident #1’s chest was moving and she was gasping for air. The funeral home then called 911 and hospice,” the report says.

When EMS personnel arrived, they recorded the woman’s pulse and noted she had no eye movement or verbal, vocal or motor response, according to the report.

The woman was taken to the emergency room. She was returned to the hospice facility and died with her family at her side two days later, according to the state report.

The state fined the facility $10,000, the maximum allowed under Iowa law, said a spokesperson for the state Department of Inspections and Appeals.

A state citation dated Wednesday said that the facility “failed to provide adequate direction to ensure appropriate cares and services were provided” and that it failed to ensure she received “dignified treatment and care at end of life.”

The hospice facility’s executive director said representatives have been in touch with the resident’s family.

“We care deeply for our residents and remain fully committed to supporting their end-of-life care,” Executive Director Lisa Eastman said in a statement. “All employees undergo regular training so they can best support end-of-life care and the death of our residents.”