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Composite Quality Score
Comprehensive rating based on CMS data, staffing, quality measures, and compliance
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Current Availability Estimate
Basic Information
3675 KILAUEA AVENUE
HONOLULU, HI 96816
155
60% (~62 available)
HAWAII HEALTH SYSTEMS CORPORATION
Quality Ratings
Safety Information
Additional Information
125010
Medicare and Medicaid
Staffing Metrics
Higher staffing hours generally indicate better care quality. Lower turnover indicates more experienced, stable staff.
Registered Nurse (RN) Hours
Per resident per day
This Facility
1.82
hours
National Avg
0.64
hours
Total Nursing Staff Hours
RN + LPN + Nurse Aides per resident per day
This Facility
4.55
hours
National Avg
3.89
hours
Breakdown:
Staff Turnover Rate
Annual nursing staff turnover
This Facility
17.7%
National Avg
46.6%
RN Turnover: 14.6%
Understanding Staffing Metrics
Staffing hours: Higher hours generally mean more staff attention per resident. Federal minimum is 3.5 total hours per resident per day, but quality facilities often exceed 4+ hours.
Turnover: High turnover (>50%) can indicate staffing issues and affect care continuity. Lower turnover means more experienced staff familiar with residents' needs.
Detailed Quality Measures
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Health Inspections & Deficiencies
Total Deficiencies
54
Inspections
3
High
2
Aug 1, 2024 - Health Survey
10 deficiencies cited
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Resident Assessment and Care Planning Deficiencies
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Pharmacy Service Deficiencies
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.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Pharmacy Service Deficiencies
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.
Resident Assessment and Care Planning Deficiencies
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Sep 14, 2023 - Health Survey
14 deficiencies cited
Resident Rights Deficiencies
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Resident Rights Deficiencies
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.
Nursing and Physician Services Deficiencies
Post nurse staffing information every day.
Pharmacy Service Deficiencies
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.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Resident Rights Deficiencies
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.
Resident Rights Deficiencies
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Nursing and Physician Services Deficiencies
Post nurse staffing information every day.
Pharmacy Service Deficiencies
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.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Sep 30, 2022 - Health Survey
30 deficiencies cited
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Resident Rights Deficiencies
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Resident Rights Deficiencies
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Resident Rights Deficiencies
Honor the resident's right to organize and participate in resident/family groups in the facility.
Resident Rights Deficiencies
Ensure that residents are fully informed and understand their health status, care and treatments.
Resident Rights Deficiencies
Give the resident's representative the ability to exercise the resident's rights.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies
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.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Resident Rights Deficiencies
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Resident Rights Deficiencies
Give the resident's representative the ability to exercise the resident's rights.
Resident Rights Deficiencies
Ensure that residents are fully informed and understand their health status, care and treatments.
Resident Rights Deficiencies
Honor the resident's right to organize and participate in resident/family groups in the facility.
Resident Rights Deficiencies
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies
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.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Understanding Deficiencies
Deficiencies are violations of federal health and safety standards identified during CMS inspections. They are categorized by scope (isolated, pattern, or widespread) and severity (potential for harm vs. actual harm).
Critical deficiencies involve actual harm to residents and should be carefully considered. Facilities typically have opportunities to correct deficiencies and implement preventive measures.
Understanding deficiencies: Not all deficiencies indicate poor care. Learn how to interpret health inspection results and identify serious warning signs. Read our guide on warning signs →
Penalties & Enforcement
No penalties or payment denials in the past 3 years
Key Highlights
Frequently Asked Questions
What is the quality rating for LEAHI HOSPITAL?
LEAHI HOSPITAL has an overall CMS rating of 5 out of 5 stars. This rating is based on health inspections, staffing levels, and quality measures reported by Medicare.
How many beds does this facility have?
LEAHI HOSPITAL has 155 certified beds. The facility averages 93 residents per day, with an occupancy rate of approximately 60%.
What type of ownership does this facility have?
This facility is government - state owned. It is part of the HAWAII HEALTH SYSTEMS CORPORATION network.
How can I contact LEAHI HOSPITAL?
You can call LEAHI HOSPITAL at (808)733-8000. The facility is located at 3675 KILAUEA AVENUE, HONOLULU, HI 96816.
What should I look for when choosing a nursing home?
When selecting a nursing home, consider: CMS star ratings (overall, health inspection, staffing, and quality measures), nurse staffing levels, staff turnover rates, recent health inspection results, complaint history, proximity to family, and available services. We recommend visiting facilities in person, talking to current residents and staff, and checking multiple sources of information before making your decision. Use our comprehensive tour checklist when visiting facilities.
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Understanding Star Ratings
What do CMS star ratings really mean? Data from 14,751 facilities reveals the truth.
Read Guide →Why Staffing Matters Most
Learn what RN hours, turnover rates, and nurse-to-resident ratios actually mean for care quality.
Read Guide →How to Read CMS Data
Decode quality measures, health inspections, and compliance reports like a pro.
Read Guide →Recognizing Warning Signs
Critical red flags that indicate neglect, abuse, or substandard care.
Read Guide →Facility Tour Checklist
What to look for, questions to ask, and red flags to watch for during your visit.
Read Guide →View All Guides
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