Cycle 1
Health 2025-07-25 · Fire 2024-08-01
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Honolulu, HI
Leahi Hospital
5-star overall rating with 4-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
3675 Kilauea Avenue, Honolulu, HI
(808) 733-8000
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
155
Certified beds
Average residents
93
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Hawaii Health Systems Corporation
Operator or chain grouping
Approved since
1969-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 facilities
Chain averages 4 overall / 3 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.86
Registered nurse staffing · state 1.63 · national 0.68
LPN hours / resident day
0.04
Licensed practical nurse staffing · state 0.36 · national 0.87
Aide hours / resident day
2.58
Nurse aide staffing · state 2.73 · national 2.35
Total nurse hours
4.47
All reported nurse hours · state 4.71 · national 3.89
Licensed hours
1.90
RN + LPN hours · state 1.97 · national 1.54
Weekend hours
3.49
Weekend nurse staffing · state 4.19 · national 3.43
Weekend RN hours
1.21
Weekend registered nurse coverage · state 1.23 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.80
CMS adjusted RN staffing hours
Adjusted total hours
4.33
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
14%
Annual RN turnover · state 33% · national 45%
Total nurse turnover
19%
Annual nurse turnover · state 37% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,047
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
60.56
Composite VBP score used to determine payment impact.
Payment multiplier
1.0157
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
10
Baseline 13.59% · Performance 10.59% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
2.11
Baseline 5.14 hours · Performance 3.68 hours · Measure score 2.11 · Achievement 2.11 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 20 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.71 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 7 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 11 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 17.99% |
8.2%
9.8 pts better
|
Numerator 34 · Denominator 189 |
| Staff flu vaccination coverage | 64.47% |
42%
22.5 pts better
|
Numerator 127 · Denominator 197 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.3
0.6 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.0 · Expected 1.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.4 |
0.9
0.5 pts better
|
1.8
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.3 · Expected 1.1 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.9% |
96.3%
0.6 pts better
|
93.4%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.0% · Q2 96.0% · Q3 96.9% · Q4 100.0% · 4Q avg 96.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.4%
4.6 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.3% |
1.9%
1.4 pts worse
|
3.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 3.0% · Q3 4.2% · Q4 4.2% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
1.4%
1.4 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 0.9% |
4.9%
4 pts better
|
5.4%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 2.3% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 6.1% |
8.2%
2.1 pts better
|
19.6%
13.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 6.8% · Q3 6.0% · Q4 5.9% · 4Q avg 6.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.4% |
11.3%
5.1 pts worse
|
16.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 17.6% · Q3 16.2% · Q4 19.1% · 4Q avg 16.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.3%
0.3 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 22.6% |
23.4%
0.8 pts better
|
16.3%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 40.0% · Q3 9.9% · Q4 26.4% · 4Q avg 22.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.8% |
16.8%
2 pts worse
|
14.9%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.4% · Q2 23.7% · Q3 14.3% · Q4 20.8% · 4Q avg 18.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
1.3%
0.4 pts better
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.6% · Q3 0.9% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.0% |
2.4%
1.4 pts better
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 0.0% · Q3 0.0% · Q4 2.1% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.7% |
17.8%
0.1 pts better
|
19.8%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.6% · Q2 26.2% · Q3 13.9% · Q4 12.8% · 4Q avg 17.7% |
| Percentage of long-stay residents with pressure ulcers | 1.3% |
3.6%
2.3 pts better
|
5.1%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 1.5% · Q3 0.8% · Q4 0.8% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.8% |
82.8%
9 pts better
|
81.7%
10.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 84.6% · Q3 93.8% · Q4 95.2% · 4Q avg 91.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.0%
1 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 84.6% |
84.7%
0.1 pts worse
|
79.7%
4.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 84.6% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-01 · Fire 2023-09-14
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-09-14 · Fire 2022-09-30
7 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-08-01
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-10-07
D · Potential for more than minimal harm
2024-08-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-18
D · Potential for more than minimal harm
2022-09-30
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-10-05
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-07-25
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-09-08
D · Potential for more than minimal harm
2025-07-25
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-09-08
D · Potential for more than minimal harm
2025-07-25
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-09-08
D · Potential for more than minimal harm
2025-07-25
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-09-08
D · Potential for more than minimal harm
2025-07-25
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-09-08
D · Potential for more than minimal harm
2025-07-25
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-09-08
F · Potential for more than minimal harm
2024-08-01
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-09-15
D · Potential for more than minimal harm
2024-08-01
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-09-15
D · Potential for more than minimal harm
2024-08-01
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-09-15
D · Potential for more than minimal harm
2024-08-01
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-09-15
D · Potential for more than minimal harm
2024-08-01
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-09-15
E · Potential for more than minimal harm
2023-09-14
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-10-27
E · Potential for more than minimal harm
2023-09-14
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-10-27
E · Potential for more than minimal harm
2023-09-14
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-10-27
D · Potential for more than minimal harm
2023-09-14
F584 · Resident Rights Deficiencies
Health
Honor 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.
Corrected 2023-10-27
D · Potential for more than minimal harm
2023-09-14
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-10-27
D · Potential for more than minimal harm
2023-09-14
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-10-27
D · Potential for more than minimal harm
2023-09-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-27
Penalties and ownership
What sits behind the stars
Ownership
Hawaii Health Systems Corporation
5% Or Greater Direct Ownership Interest · Organization
Akiyoshi, Derek
Corporate Officer · Individual
Azama, Garet
Corporate Director · Individual
Chun, Bradley
Corporate Director · Individual
Gonzales, Violeta
W-2 Managing Employee · Individual
Hamamoto, Michael
Corporate Officer · Individual
Hawaii Health Systems Corporation
Operational/Managerial Control · Organization
Rosen, Linda
Corporate Officer · Individual
Sanada, Sean
Corporate Officer · Individual
Sunada, Jared
Corporate Director · Individual
Tsuneishi, Lani
Corporate Director · Individual
Walker, Ken
Corporate Director · Individual
Woo, Jason
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Hi'olani Care Center at Kahala Nui
Honolulu, HI
5-star overall rating with 3-star inspections with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Maunalani Nursing And Rehabilitation Center
Honolulu, HI
5-star overall rating with 5-star inspections with $32,133 in total fines with 3 recent health deficiencies
#3
Palolo Chinese Home
Honolulu, HI
2-star overall rating with 2-star inspections with $12,735 in total fines with 22 recent health deficiencies
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