A+
96/100

LEAHI HOSPITAL Inspection Report, Violations & Safety Grade (HONOLULU, Hawaii)

3675 KILAUEA AVENUE, HONOLULU, Hawaii 96816

Phone: 8087338000

CMS Overall:5/5

Overview & Bed Count

Certified Beds
155
Avg Residents/Day
92.5
Ownership
Government - State
Provider Type
Medicare and Medicaid
County
Honolulu
Sprinkler Systems
Yes
Special Focus
None
Abuse Citation
No

CMS Star Ratings

Overall5/5
Health4/5
Staffing5/5
Quality5/5

Nurse Staffing Check

MetricThis FacilityHawaii AvgDifference
RN Hours per Resident per Day1.911.73+0.18
Total Nurse Hours per Resident per Day4.534.99-0.46
CMS Staffing Rating5/54.5/5-
Nursing Staff Turnover16.5%34.5%-

Health Citation History

18 health citations on record

DateCategoryDescriptionSeverity
2025-07-25Nutrition and Dietary DeficienciesProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.E – Moderate Harm Potential
2025-07-25Resident Rights DeficienciesProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.D – Moderate Harm Potential
2025-07-25Resident Assessment and Care Planning DeficienciesDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.D – Moderate Harm Potential
2025-07-25Quality of Life and Care DeficienciesEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.D – Moderate Harm Potential
2025-07-25Quality of Life and Care DeficienciesProvide safe and appropriate respiratory care for a resident when needed.D – Moderate Harm Potential
2025-07-25Pharmacy Service DeficienciesEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.D – Moderate Harm Potential
2024-08-01Administration DeficienciesSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.F – Moderate Harm Potential
2024-08-01Resident Assessment and Care Planning DeficienciesCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.D – Moderate Harm Potential
2024-08-01Pharmacy Service DeficienciesEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.D – Moderate Harm Potential
2024-08-01Freedom from Abuse, Neglect, and Exploitation DeficienciesTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.D – Moderate Harm Potential
2024-08-01Freedom from Abuse, Neglect, and Exploitation DeficienciesRespond appropriately to all alleged violations.D – Moderate Harm Potential
2023-09-14Freedom from Abuse, Neglect, and Exploitation DeficienciesTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.E – Moderate Harm Potential
2023-09-14Freedom from Abuse, Neglect, and Exploitation DeficienciesRespond appropriately to all alleged violations.E – Moderate Harm Potential
2023-09-14Resident Rights DeficienciesProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.E – Moderate Harm Potential
2023-09-14Resident Rights DeficienciesHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.D – Moderate Harm Potential
2023-09-14Nursing and Physician Services DeficienciesPost nurse staffing information every day.D – Moderate Harm Potential
2023-09-14Pharmacy Service DeficienciesEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.D – Moderate Harm Potential
2023-09-14Infection Control DeficienciesProvide and implement an infection prevention and control program.D – Moderate Harm Potential

Fire Safety Citation History

3 fire safety citations on record

DateCategoryDescriptionSeverity
2024-08-01Miscellaneous DeficienciesTo conduct inspection, testing and maintenance of fire doors by qualified individuals.D – Moderate Harm Potential
2024-08-01Gas, Vacuum, and Electrical Systems DeficienciesHave generator or other power source capable of supplying service within 10 seconds.D – Moderate Harm Potential
2022-09-30Gas, Vacuum, and Electrical Systems DeficienciesHave proper medical gas storage and administration areas.D – Moderate Harm Potential

Total Penalties & Fines

$0
Total Fine Amount (CMS)
0
Number of Fines
0
Total Penalties

No penalty records found.

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