Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
LILIHA HEALTHCARE CENTER
HONOLULU, HI · 92 certified beds · Last Life Safety survey January 31, 2025
CMS Certification Number 125041 · first certified February 1995
Ownership
Independently operated (no chain recorded by CMS) · For profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within HI
8 citations — more than 81% 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 3. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Past the typical window (February 2026 to July 2026). Most US facilities have been surveyed by March 2027. This facility’s last Life Safety survey was January 2025. 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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1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
2 of the 8 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
9 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 8 Life Safety citations above. The Physical Environment Index
- 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-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0880 Provide and implement an infection prevention and control program.
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- F-0908 Keep all essential equipment working safely.
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 | 8 |
| Median facility in HI | 4 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| February 14, 2023 | 4 |
| January 26, 2024 | 2 |
| January 31, 2025 | 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. | 2 | 2024-01-26 |
| E-0037 | Establish staff and initial training requirements. | 1 | 2023-02-14 |
| K-0531 | Have elevators that firefighters can control in the event of a fire. | 1 | 2023-02-14 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 1 | 2025-01-31 |
| E-0001 | Establish an Emergency Preparedness Program (EP). | 1 | 2023-02-14 |
| K-0541 | Install properly constructed and protected linen or trash chutes. | 1 | 2025-01-31 |
| K-0293 | Have properly located and lighted "Exit" signs. | 1 | 2024-01-26 |
What the citations cover
- Services Deficiencies 2
- Emergency Preparedness Deficiencies 2
- Miscellaneous Deficiencies 2
- Smoke Deficiencies 1
- Other 1
| Category | Citations |
|---|---|
| Services Deficiencies | 2 |
| Emergency Preparedness Deficiencies | 2 |
| Miscellaneous Deficiencies | 2 |
| Smoke Deficiencies | 1 |
| Egress Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
January 31, 2025 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (March 12, 2025) |
| K-0541 | Install properly constructed and protected linen or trash chutes. | Deficient, Provider has date of correction (March 12, 2025) |
January 26, 2024 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (April 10, 2024) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Waiver has been granted (April 30, 2024) |
February 14, 2023 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0001 | Establish an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (May 5, 2023) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (May 11, 2023) |
| K-0531 | Have elevators that firefighters can control in the event of a fire. | Deficient, Provider has date of correction (May 5, 2023) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Waiver has been granted (May 5, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.