Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
LEAHI HOSPITAL
HONOLULU, HI · 155 certified beds · Last Life Safety survey August 1, 2024
CMS Certification Number 125010 · first certified January 1969
Ownership
Operated by HAWAII HEALTH SYSTEMS CORPORATION · Government - State
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within HI
3 citations — more than 38% of the 43 certified nursing homes in HI. Compared within HI rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 2 citations; the earlier surveys in the window averaged 0.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (August 2025 to January 2026), and past the point by which nine in ten US facilities have been surveyed. This facility’s last Life Safety survey was August 2024. Nursing homes nationally are typically surveyed 12–17 months after the last one (median 14), measured over 19,385 consecutive surveys in the last two years of CMS records. HI has too few recent surveys to measure on its own, so the national interval is used.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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Physical environment (health survey)
3 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 3 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0584 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.
- F-0880 Provide and implement an infection prevention and control program.
How that compares
Compared with the median facility in HI, and nationally. Surveyors differ markedly between states, so the HI figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 3 |
| Median facility in HI | 4 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| September 30, 2022 | 1 |
| September 14, 2023 | 0 |
| August 1, 2024 | 2 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 1 | 2024-08-01 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 1 | 2024-08-01 |
| K-0923 | Have proper medical gas storage and administration areas. | 1 | 2022-09-30 |
What the citations cover
- Gas, Vacuum, and Electrical Systems Deficiencies 2
- Miscellaneous Deficiencies 1
| Category | Citations |
|---|---|
| Gas, Vacuum, and Electrical Systems Deficiencies | 2 |
| Miscellaneous Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
August 1, 2024 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (October 7, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (September 18, 2024) |
September 30, 2022 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (October 5, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.