Care Center of Honolulu: Stage Four Ulcer Care Fails - HI
The resident at The Care Center of Honolulu explained his situation during an August inspection. "I have a sore on my back that's infected and pretty deep," he said. "I'm supposed to be turned every two hours but there isn't always enough staff available. It takes two Certified Nurse Aides to do it, and one CNA can't do it by themself."
The resident, identified in inspection records as R126, said he takes antibiotics for the infected wound. He expressed frustration about basic comfort needs going unmet. "I wish I could turn or get a pillow," he told inspectors. "When they came in to change the bed, they moved the extra pillows and I didn't get them back, they must be in short supply."
Federal inspectors found the facility failed to provide treatment consistent with professional standards to promote healing and prevent infection of the existing stage four pressure ulcer. The resident required maximum assistance from staff but was not repositioned off the wound at least every two hours, placing him at risk of worsening the deep injury.
R126 is cognitively intact and dependent on staff for toileting, bathing and dressing, according to facility records. He requires partial to moderate assistance to roll left and right and is dependent on staff for transfers from bed to chair. The stage four pressure ulcer was present when he was admitted to the facility.
During the inspection on August 12, inspectors observed R126 in his bed on his back with the head of the bed elevated 45 degrees at 9:04 AM. He told them he "used to walk pretty well before but now I'm in bed all the time."
Stage four pressure ulcers represent the most severe category of pressure injuries, extending through the full thickness of skin and into underlying muscle, tendon or bone. These wounds require intensive treatment protocols including frequent repositioning to relieve pressure and promote healing.
The facility's care plan for R126, dated July 15, 2023, acknowledged his mobility impairment and established goals to keep him free of complications related to immobility, including contractures, blood clots, skin breakdown and fall-related injuries.
A separate mobility violation involved another resident whose care plan specified being up in a wheelchair at 10:30 AM daily. Records from August 2 through August 14 showed this resident was documented as up in a chair on only two days - August 3 at 2:13 PM and August 10 at 12:19 PM. On all other days, the resident remained in bed despite the care plan requirements.
The facility's plan of care called for staff to turn and reposition residents to the right side, left side, back and chair. A restorative nurse aide was assigned to monitor and document signs and symptoms of immobility complications, including contractures forming or worsening, blood clot formation, skin breakdown and fall-related injuries.
Federal inspectors classified both violations as causing minimal harm or potential for actual harm, affecting few residents. However, the citation noted that all residents requiring maximum assistance from staff have the potential to be affected by inadequate repositioning practices.
The Care Center of Honolulu is located at 1900 Bachelot Street and was inspected on August 15, 2024. The facility treats residents with complex medical conditions including heart failure, septicemia and wound infections requiring specialized nursing care.
Pressure ulcers develop when sustained pressure restricts blood flow to tissue, causing cell death and tissue breakdown. Stage four ulcers can take months or years to heal and carry significant risks of infection, sepsis and death if not properly managed.
The resident's account of inadequate staffing preventing proper repositioning highlights a common challenge in nursing homes where labor-intensive care requirements often exceed available staff resources. Two-person transfers and repositioning require coordination between multiple caregivers, creating scheduling difficulties when facilities operate with minimal staffing levels.
R126's infected pressure ulcer required antibiotic treatment, indicating the wound had progressed beyond simple tissue breakdown to active bacterial infection. Without proper pressure relief through regular repositioning, infected stage four ulcers can worsen rapidly and lead to life-threatening complications.
The resident's simple request for pillows that were removed during bed changes and never returned illustrates how basic comfort measures can be overlooked in understaffed facilities. Proper positioning with supportive pillows is a fundamental component of pressure ulcer prevention and treatment.
Federal regulations require nursing homes to provide necessary care and services to promote healing and prevent deterioration of existing pressure ulcers. The facility's failure to consistently reposition R126 off his infected stage four ulcer violated these standards and placed him at risk of further tissue damage and systemic infection.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Care Center of Honolulu from 2024-08-15 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
THE CARE CENTER OF HONOLULU in HONOLULU, HI was cited for violations during a health inspection on August 15, 2024.
The resident at The Care Center of Honolulu explained his situation during an August inspection.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.