TONAWANDA, N.Y. (WIVB) — The New York State Department of Health released a new report, detailing the events of the day Judith Schrecengost was found dead in an outdoor courtyard in early February.

The report says the Safire Care Rehabilitation of Northtowns in Tonawanda put its residents, particularly Schrecengost, in ‘immediate jeopardy’ in February 2022. The DOH launched this investigation after Schrecengost fell from a third-story window on a freezing winter day.

“I wanted to call my mom last week and like I can’t,” Tine Delgrolice, Schrecengost’s daughter, said.

Delgrolice said it was an emotional day Tuesday when she read the details of her mother’s death in the report. She says she always loved her mother’s cooking and would call her with questions on how to perfect recipes. Delgrolice smiled when saying she just cannot make stuffed peppers as her mom could.

Schrecengost was last seen on Feb. 7 and was found dead the following days. The report says she was seen on surveillance video walking the hallways before entering a resident room on the third floor. She never returned out of the room and staff found her the following day in the courtyard below.

According to the report by the NYSDOH, she fell out of the window. It is alleged that the window was more than six inches open, allowing a person to fall through it.

“[It] Should’ve only been able to be opened about six inches and was able to be opened much further that a person could fit out of it,” Michael Scinta, attorney with Brown Chiari, LLP, said.

The report says Safire failed to provide a safe environment and supervision for Schrecengost.

The State’s website shows that 163 nursing home complaints have been made against the facility from May 2018 through April 2022. Safire Rehabilitation has been fined five times since 2016 by the NYSDOH, three of those were in 2021.

“They continually put profits over people. They’ve been fined before. They’ve had DOH citations before. And they’ve had similar instances at other facilities that they are involved with as well,” Scinta added.

In the report, Safire says its employees are now required to complete a formal resident check once every eight-hour shift and perform visual checks every two hours. Other requirements and action plans are detailed in the report.

Delgrolice describes her mother as a sweetheart, always putting others before herself. Her most treasured memory is sitting in their backyard looking through catalogs on plants.

“We’d grab it. We always had like four copies. Go on the back porch and figured out what flowers we wanted to order and where we were going to put them. Just simple little things like that,” Delgrolice said.

Attorney Scinta says his firm will finish its investigation soon and that the family plans to file a lawsuit after that.

Safire Rehabilitation has not responded to News 4’s request for comment on Tuesday.

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Tara Lynch is a Buffalo native who joined the News 4 team as a reporter in 2022. She previously worked at WETM in Elmira, N.Y., a sister station of News 4. You can follow Tara on Facebook and Twitter and find more of her work here.