The resident wiped away tears as she recounted the incident to state inspectors at Villa Las Palmas Healthcare Center. She had called for help around 11 p.m. on April 22 to be pulled up in bed when her assigned nursing assistant brought a colleague for assistance.
"Oh, it's you. You been here long enough and should be able to pull yourself up," the second nursing assistant told her, according to the resident's account. The staff member then laughed and pointed at her while saying, "Look at you, you're four times bigger than me."
The nursing assistant told the resident she didn't want to break her back by pulling her up and that the resident was too big. The resident described feeling worthless after the encounter.
"I just want to go home with my family," she told inspectors during their May 1 visit.
Her husband, who was present during the interview, said the incident had a bad effect on his wife after decades of marriage. The resident said she initially felt disbelief, then felt bad and worthless.
"The incident felt like abuse because CNA 2 had been yelling at her, it happened at night, and she was alone and in a helpless state," according to the inspection report. "I didn't feel safe."
The resident added that everyone knew the nursing assistant was rude, even housekeepers.
A housekeeper confirmed the reputation during her interview with inspectors. She said about three to four weeks earlier, while cleaning a room on another unit, a resident told her the same nursing assistant was rude to them. The housekeeper never reported what she heard.
The nursing assistant who witnessed the abuse provided more details to inspectors. She said her colleague spoke loudly in the hallway outside the resident's room, stating she wasn't going to break her back and that "the resident's 500 times my weight."
The colleague followed her into the resident's room while asking, "How could someone let themselves get that big?" She then told the resident directly: "We're not going to do this, you're going to do it. Don't you see how big you are?"
The resident started crying while the nursing assistant kept talking about her weight. "I couldn't take it anymore and told [CNA 2] she was rude and to get out of my resident's room," the witnessing staff member told inspectors.
She said this was her first time working with the abusive colleague. After reporting the incident to the charge nurse and emailing the Director of Staff Development, she had to take a break because she was emotional after witnessing what happened.
"Emotionally damaging [to] the resident," she called it, identifying the behavior as emotional abuse based on her facility training. She described the victim as very sweet, never getting mad, and considerate — not the type to complain.
The charge nurse on duty that night received the initial report but failed to investigate properly. She asked the accused nursing assistant what happened, and the staff member denied saying anything to the resident. When the charge nurse spoke to the resident about the incident, the woman didn't want to discuss what occurred.
"What CNA 1 told her was vague and that she had not clarified what was told to her," according to the inspection findings.
When inspectors informed the charge nurse of the full details residents and staff had provided, her response was immediate: "Oh no, that's abuse."
She acknowledged that based on her facility abuse prevention training, the incident constituted verbal, emotional, and mental abuse. Had she known all the details, she said she would have sent the nursing assistant home. Instead, the staff member worked the entire night shift providing care to residents.
Another charge nurse explained proper protocol during her interview. When staff rudeness to a resident is reported, she would "get all the facts" and contact the Director of Operations and Director of Nursing for guidance to determine if the incident was rudeness or abuse. If abuse appeared to have occurred, she would send the staff member home.
The Director of Staff Development confirmed that verbal abuse had occurred and that the resident suffered emotional distress. "It was verbal and mental abuse," she told inspectors.
The nursing assistant had a documented history of problems. She received written warnings on April 2 and April 10 for negatively talking about residents, constantly complaining about management and staff, and speaking loudly where everyone could hear.
After receiving the midnight email about the incident, the director said she initially thought the staff member "was being negative again and I could address it the morning." She acknowledged that additional training should have been provided to licensed nurses in charge positions on how to gather facts and report to administrators for guidance.
The facility's own training materials clearly defined the violations that occurred. The abuse prevention lesson plan stated that mental and emotional abuse includes "actions or words that inflict psychological abuse or trauma," with examples including staff telling residents "You're useless," causing them to cry.
Verbal abuse was defined as "the use of words to cause emotional pain, fear, or distress," with examples including nurses yelling at residents in front of others: "You're a burden to everyone here!"
The Director of Operations and Director of Nursing admitted they initially didn't think the April 22 incident was as serious as it turned out to be. Considering how the resident perceived the incident and how it made her feel, they concluded it was abuse.
"Verbal abuse as [Resident 1] experienced emotional distress from it," the Director of Nursing said.
They acknowledged the charge nurse could have asked more questions and gathered more details, which would have provided enough information to send the abusive staff member home immediately. The administrators said the charge nurse should have reached out for guidance in identifying the behavior as abuse.
The facility's abuse prevention policy, revised in September 2022, explicitly prohibited abuse of any kind and required staff to identify different types of abuse. Mental abuse was defined as verbal or non-verbal conduct causing residents to experience humiliation, intimidation, fear, shame, agitation or degradation.
Examples included harassing residents, mocking, insulting, ridiculing, and yelling or hovering with intent to intimidate.
Despite these clear guidelines and training requirements, supervisors failed to recognize obvious abuse when it was reported, allowing the perpetrator to continue working with vulnerable residents throughout the night.
The facility also failed two other residents by not developing required fall prevention care plans within 48 hours of admission, despite identifying them as high fall risks. Both residents had documented fall-related diagnoses — one with unsteadiness on feet, another with repeated falls — yet received no immediate interventions to prevent future injuries.
The resident who endured the weight-shaming abuse was readmitted to Villa Las Palmas on May 1, the same day inspectors arrived to investigate her complaint. Her tears during the interview reflected the lasting impact of being mocked and refused care during a vulnerable moment when she needed help.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Villa Las Palmas Healthcare Center from 2025-05-05 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Villa Las Palmas Healthcare Center
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