Care Center of Honolulu: 12 Deficiencies Found - HI
Federal inspectors found the paralyzed patient at The Care Center of Honolulu lying in bed with his call light placed on the mattress beside his pillow — completely out of reach — on multiple days in September. The resident, identified as R78 in inspection records, is cognitively intact and fully aware when he needs help.
"Yes, if I can reach it with my head," R78 told an inspector who asked if he could use the call light for assistance. The resident then asked the inspector to activate the button so staff would come reposition it closer to his head.
R78 was admitted for long-term care with quadriplegia, meaning paralysis in all four limbs and torso. He also has a surgical opening in his neck where a tube maintains his airway. His most recent cognitive assessment scored 15 out of 15 points, indicating he is mentally sharp and fully understands his situation.
When the inspector pressed the call button on September 2nd, a certified nursing aide arrived within one minute. R78 immediately asked the aide to move the call light closer to his head so he could reach it. The aide acknowledged it was out of reach and pinned it to the left side of his pillow.
Two days later, inspectors found the same problem. R78 was lying in bed with his eyes closed, and his call light was again placed on the mattress near his pillow — out of reach.
The pattern revealed a systemic failure. Staff knew exactly what R78 needed and how to position the call button properly, yet repeatedly left him unable to summon help.
A nurse supervisor confirmed to inspectors that staff are required to ensure R78 can always reach his call light, since he is capable of activating it when positioned correctly. The supervisor's acknowledgment came only after inspectors shared their observations of the call light being consistently out of reach.
For a resident with R78's medical conditions, access to emergency assistance is critical. Quadriplegia leaves him unable to move his arms or legs, while his tracheostomy requires careful monitoring. Any respiratory distress, equipment malfunction, or medical emergency would require immediate staff intervention.
The violation puts R78 at risk of not having urgent needs met in a timely manner. Federal inspectors noted the deficient practice could potentially affect all residents at the facility who rely on call lights for assistance.
The failure is particularly troubling because R78 clearly communicated his needs. He knew precisely how staff should position the call button and directly asked for help when inspectors were present. His cognitive assessment shows he fully understands his situation and can advocate for proper care.
Yet staff repeatedly failed to follow through on basic positioning that would allow him to call for help. The violation occurred despite R78's clear instructions and the aide's acknowledgment that the call light was improperly placed.
The facility is disputing the citation, according to inspection records. However, inspectors documented the same positioning problem across multiple days and shifts, suggesting the issue was not isolated to individual staff members but reflected broader care practices.
Call light accessibility represents one of the most fundamental safety requirements in nursing home care. For residents who cannot move independently, the ability to summon help serves as their primary protection against medical emergencies, equipment failures, and urgent care needs.
R78's situation illustrates how seemingly minor oversights can leave vulnerable residents completely dependent on staff remembering to check on them, rather than being able to call for help when needed. His paralysis makes him entirely reliant on others, yet staff repeatedly left him without his primary means of communication.
The inspection found R78 watching television during one observation, alert and aware of his surroundings, but unable to reach the one device that could connect him to assistance if something went wrong.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Care Center of Honolulu from 2025-11-19 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 November 19, 2025.
The resident, identified as R78 in inspection records, is cognitively intact and fully aware when he needs help.
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.