Leahi Hospital

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

Therapy staffing: this home’s payroll records show 0.24 therapist hours per resident per day in 2026Q1 — more than 33% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 155 beds and averages 93.2 residents a day — about 60% occupied, or roughly 62 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.55 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.82 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.71 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.66 hrs/resident/day on weekends vs 4.92 on weekdays — 26% thinner on weekends — a notable drop. RN hours go from 2.05 to 1.24 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 18% is below the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

18 citations, most serious first. The 10 most serious are shown; the remaining 8 are one tap away and print in full.

• Potential for harm · E2025-07-25 · tag F0812 — failed to store, cook, and serve food safely — pattern
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, staff interviews and policy review, the facility failed to: 1) Discard an expired container of Lemon Juice that was stored the kitchen refrigerator and 2) Label a supplement drink stored in the resident's kitchen refrigerator with the opened-on date once it was opened. As a result of this deficiency, the facility put residents at risk for foodborne illness.Findings Include:1) During the initial tour of the kitchen, on 07/22/25 at 08:50 AM, a one-gallon container of Lemon Juice, in the refrigerator, was labeled with an expiration date of 07/19/25. The container was half full and was located on the middle shelf. Staff interview on 07/22/25 at 08:52 AM, Kitchen Manager (KM) acknowledged that the Lemon Juice container was expired and should have been discarded. KM removed the Lemon Juice container and said they would discard it immediately. Review of facility policy on Food Labeling read; Purpose, to ensure that all foods served at the facility are fresh. Outdated foods that are kept beyond their allowed shelf life are not to be used in food production or served…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-07-25 · tag F0628 — isolated
  Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide the effective date of discharge in the discharge notice for one Resident (R) 98 of three residents sampled for the transfer discharge process when he was transferred to a hospital. The deficient practice has the potential misinform the representative of the Residents date of transfer. Findings include:On 06/03/25 progress notes reviewed. Resident (R) 98 was admitted to the facility on [DATE] for Physical Therapy (PT) and Occupational Therapy (OT) with a primary diagnosis of Pneumonia and Parkinson's disease. R98 was transferred to an acute care hospital three days later on 06/06/25 for respiratory failure secondary to recurrent aspiration pneumonia. On 07/24/25 reviewed the discharge and transfer notice with email documentation that was sent to the Long-Term Care Ombudsman (LTCO). The notice that was provided to the resident's representative and the LTCO did not have the date of the transfer written on the notice. On 07/25/25 at 10:30 AM,…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-07-25 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interviews, and record review, the facility failed to implement the care plan for one resident (Resident (R), R38) sampled for accidents and R92, who was sampled for respiratory care. The deficient practice puts R38 at risk for falls that could result in harm if the mechanical lift is not used appropriately with two staff and puts R92 at risk for respiratory infection who already has compromised health. Cross reference to F689 1) On 07/22/25 at 08:30 AM, observed Certified Nurses Aide (CNA) 41 transferring R38 from bed to wheelchair using a mechanical lift on her own. When CNA41 was asked if the facility policy allowed her to transfer a resident using the mechanical lift by herself, CNA41 stated that she was able to if she felt capable and that R38 trusted her to do it. On 07/24/25 at 08:15 AM, interview with Head Nurse (HN) 6 and confirmed that transfers using the mechanical lift should always be completed with two staff. HN6 noted that this is for the resident's safety. HN6 also confirmed that this is noted in R38's care plan, which is accessible to all staff…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-07-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interviews, and record review, the facility failed to ensure that one of one resident (Resident (R), R38) sampled for accidents was free from accident hazard when staff transferred R38 using a mechanical lift with only one person assist. This deficient practice has the potential to affect all residents requiring transfers using a mechanical lift.Findings Include:On 07/22/25 at 08:30 AM, observed Certified Nurse's Aide (CNA) 41 transferring R38 from bed to wheelchair using mechanical lift on her own. When CNA41 was asked if the facility policy allowed her to transfer a resident using the mechanical lift by herself, CNA41 stated that she was able to if she felt capable and that R38 trusted her to do it. On 07/22/25 at 09:00 AM, interview with Registered Nurse (RN) 9. RN9 said that transfers using the mechanical lift should be done with two staff for safety reasons.On 07/24/25 at 08:15 AM, interview with Head Nurse (HN) 6, and confirmed that transfers using the mechanical lift should always be completed with two staff. HN6 noted that this is for resident's…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-07-25 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  Provide safe and appropriate respiratory care for a resident when needed.
  What the surveyor found here — the official record, unedited, may be distressing

  Based on observations and interviews the facility failed to label the oxygen tubing that was connected to the oxygen (O2) concentrator with the date if initiation for one of one resident (R) 92, sampled for respiratory care. This deficient practice put R92 at risk for infection. Findings Include: On 07/22/25 at 09:04 AM and on 07/23/2025 at 10:31 AM observed R92's oxygen (O2) concentrator in her room near the wall that had tubing connected to it which was not labeled with the date of first use. On 07/24/25 at 10:43 AM interviewed 4th floor Head Nurse (HN) 6 in R92's room. Inquired of HN6 if the O2 tubing, that was attached to the O2 concentrator, should have a date when it was initiated and she confirmed this.On 07/25/25 at 10:15 AM interviewed Director of Nursing (DON) by phone regarding R92's oxygen use. Inquired if R92 had an order for oxygen and the DON confirmed that the resident had an order for Titrate Oxygen per nasal cannula PRN . and confirmed the oxygen tubing has to be labeled with the date it was initiated (opened and attached).

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-07-25 · tag F0761 — failed to label and store drugs safely — isolated
  Ensure 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.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and review of the facility's Storage of Medication Policy, the facility failed to discard two vials of expired Influenza (flu) vaccine in Young 4's medication refrigerator. This deficient practice has the potential to affect all residents in the facility due for flu vaccination.Findings Include:On 07/24/25 at 08:15 AM, medication refrigerator was checked with Registered Nurse (RN) 9. Observed two vials of expired flu vaccine dated 06/2025 still in the refrigerator located on Young 4. RN9 said that it should have been discarded last month for safety purposes. On 07/25/25 at 08:30 AM, interview with Head Nurse (HN) 6 also noted that it should have been discarded and confirmed that discarding expired medications is for the safety of the residents and to ensure the efficacy of drugs given. Review of the facility's Storage of Medication policy dated 2007 on 07/25/25 at 11:00 AM, in the Procedures section, int notes, 14. Outdated, contaminated, discontinued or deteriorated medications.are immediately removed from stock, disposed of according to procedures…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2024-08-01 · tag F0867 — failed to act on quality-improvement findings — widespread
  Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview, record review, facility document review and facility policy review, the facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI). Specifically, the facility failed to ensure corrective action was implemented and maintained to ensure sustained compliance with reporting and investigating alleged allegations of abuse. This had the potential to affect all residents that resided in the facility. Findings included: The Department of Health and Human Services Center for Medicare and Medicaid Services [CMS] Form CMS-2567's, dated 09/20/2021, 09/30/2022, and 09/14/2023, revealed the facility received deficiencies for F609 and F610 each year. The facility's Quality Assurance & Performance Improvement (QAPI) Plan 2023-2024, reviewed by the facility on 07/21/2022, revealed, Decisions will be made to promote excellence in quality of care, resident choice, person directed care, and resident transitions. Focus area will include systems that affect resident and family satisfactions, quality of care, and services provided, and all areas that…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-08-01 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review, interview, and facility policy review, the facility failed to report abuse investigation results within five working days to the state survey agency for 2 (Resident #302 and Resident #28) of 6 residents reviewed for abuse. Findings included: A facility policy titled, Prevention of Resident Abuse, Neglect, Involuntary Seclusion and Misappropriation of Property, dated 11/03/2021, revealed the section titled IV. Procedure included 6. Within two (2) hours, the DON [Director of Nursing]/Administrator/Nursing Supervisor on duty shall notify by email, phone or FAX [facsimile] the following State Agencies as required by State law through established procedures of the reported incident and findings within five (5) working days from the day the discovery. The policy revealed the State Agencies listed to report the incident to included Adult Protective Services (APS) and Office of Health Care Assurance (OHCA). 1. An admission Record indicated the facility admitted Resident #302 on 05/13/2022. According to the admission Record, the resident had a medical history that…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-08-01 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview, record review, and facility document and policy review, the facility failed to provide evidence that an allegation of abuse was thoroughly investigated for 1 (Resident #302) of 6 residents reviewed for abuse. Findings included: A facility policy titled, Prevention of Resident Abuse, Neglect, Involuntary Seclusion and Misappropriation of Property, dated 11/03/2021, revealed the section titled, I. Purpose included, B. To report and conduct a thorough investigation of all incidents within specified timelines and provide appropriate corrective actions and preventive measures. The policy also specified that when investigating allegations of abuse, investigators will, e. Conduct and document all necessary interviews with staff, witnesses, resident, and alleged perpetrator as deemed necessary. An admission Record indicated the facility admitted Resident #302 on 05/13/2022. According to the admission Record, the resident had a medical history that included diagnoses of Parkinson's disease, multiple sclerosis, chronic obstructive pulmonary disease (COPD), and visual…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-08-01 · tag F0644 — isolated
  Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review, interview, and facility policy review, the facility failed to refer residents with newly evident or possible serious mental disorder, intellectual disorder, or related condition, to the state-designated mental health or intellectual disability authority for review. The deficiency affected 2 (Resident #9 and Resident #39) of 2 residents reviewed for Pre-admission Screening and Resident Review (PASARR; PASRR) services. Findings included: A facility policy titled, Preadmission Screening Resident Review (PASRR), dated 06/07/2018, revealed the section titled II. Policy, included, E. Social Services will be contacted for assistance with Level II evaluations and for any significant mood or behavior changes that may necessitate a Level II evaluation at any time throughout the resident's stay at [the facility]. The policy revealed the section titled, IV. Procedure, included, C. Nursing Supervisor, Unit Manager and Social Worker will review PASRR for Part C exceptions for individuals with MI [mental illness] or ID [intellectual disability]/DD [developmental disability]…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to HAWAII HEALTH SYSTEMS CORPORATION — 7 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 13 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

What families pay in HI