Family members said the fall that was caught on camera shouldn't have happened. The Wellshire Warren Barr nursing home Is now under new management, but that change may have caused another set of problems.
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In the video, an 87-year-old resident falls face-first to the ground.
"It kills me inside because you don't want to see your family member go through this," said Andrea Contreras.
Contreras said she was called to Wellshire Warren Barr nursing home after her mother, Marilyn Glass, fell out of her wheelchair in April of 2022.
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"There was no foot petals on my mother's wheelchair. They actually pulled the wheelchair from the front and jerked enough, where she just went flying forward and landed on her face," Contreras said.
When Contreras arrived, she said she was told a doctor had not yet seen her mother. So she asked employees to call 911 and she called the police.
"It's horrible that should never happen to any family members of yours ever or anybody that you know. You expect people to take care of your family," she said.
Lincolnshire police made a report and obtained the video of Glass's fall. The Illinois Department of Public Health investigated and found the facility "failed to ensure a wheelbound resident was transported in a safe manner."
READ MORE: Anger abounds, questions unanswered after Lincolnshire, IL nursing home left unstaffed
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Glass's care plan states she is at high risk for falls and is "to have leg rests on at all times during transport," and while she is "in her wheelchair, to make sure her footrests are on for safety."
IDPH found Wellshire in violation of Improper Nursing Care and Resident Injury, and fined them $1,100.
The ABC7 I-Team contacted the nursing home, which recently changed ownership. The new owners declined to comment. The previous owners, who were in charge during Glass's fall, did not reply to the I-Team's request for comment.
As the nursing home changed ownership on May 1, there was also a scare for patients' family members. Families of residents called police and state officials saying there was not enough medical staff onsite to care for patients
"They were calling 911 just to get their parents out because they needed care," said Ceil Barrie.
"You have a responsibility, licensed by the state, to provide care, and you didn't do it," said David Blair, who had his mother moved from the nursing home.
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Under the Freedom of Information Act, the I-Team obtained the IDPH investigation reporting the day of staff absence at the facility, which is now called Wealshire Center of Excellence.
While the incident is "still under review," the report states that for the 108 residents there was no medical director on staff, there were no licensed nurses in the building from 8 a.m. to 11 a.m., multiple residents were taken to the hospital or home by family, due to lack of care patients did not receive their morning medications and due to lack of staff patients did not get out of bed.
A spokesperson for the new owners sent a statement, saying, "The Wealshire in Lincolnshire has been under new management and is cooperating with the Illinois Department of Public Health's review. The facility is fully staffed and meets all state requirements for care."
Contreras said she's upset over the absence of sufficient staff during the transition, and about her mother's wheelchair fall.
"I have to be strong for her. She can't do that, and she would want me to do the right thing for her and for others," she said.
Contreras said her mother is still in the same nursing home facility, but she is looking at options to possibly move her. However, there are challenges with finding her mother a new home because she lives out of state.