Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Leahi Hospital during CMS and state inspections, most recent first.
Surveyors found an expired container of lemon juice in the kitchen refrigerator and an opened supplement drink in a resident's refrigerator that was not labeled with the date it was opened. Staff confirmed both items were not handled according to facility policy, resulting in a deficiency related to food storage and labeling practices.
A resident admitted for PT and OT with pneumonia and Parkinson's disease was transferred to a hospital for respiratory failure secondary to recurrent aspiration pneumonia. The discharge notice provided to the resident's representative and the LTCO did not include the effective date of transfer, as confirmed by the SSD.
A CNA transferred a resident using a mechanical lift without the required second staff member, contrary to the care plan and facility policy. In a separate case, a resident on hospice with an order for PRN oxygen did not have oxygen therapy interventions documented in the care plan, despite facility policy requiring such documentation.
A resident was transferred from bed to wheelchair using a mechanical lift by a CNA working alone, contrary to facility policy and training that require two staff for such transfers. Staff interviews and policy review confirmed that two-person assistance is mandated for safety, but the CNA proceeded alone, stating confidence in her ability and the resident's trust.
A resident's oxygen concentrator tubing was found in use without a label indicating the date of initiation. Both the head nurse and DON confirmed that the tubing should have been labeled with the start date, as required for respiratory care equipment.
Two vials of expired influenza vaccine were found stored in a medication refrigerator, and both an RN and the Head Nurse confirmed these should have been discarded for safety and efficacy. Facility policy requires immediate removal and disposal of outdated medications, but this was not followed.
The facility's QAPI program was ineffective in addressing abuse reporting and investigation, as evidenced by repeated deficiencies in consecutive years. Despite discussions in QAPI meetings, there was no focus on ensuring investigations were completed per policy. The absence of a specific PIP for abuse reporting contributed to the facility's failure to maintain corrective actions, potentially affecting all residents.
The facility failed to refer two residents with newly diagnosed serious mental disorders to the state-designated authority for review. Despite having policies in place, the facility did not update PASARR Level I screens post-admission, resulting in missed referrals for necessary Level II evaluations.
The facility failed to lock medication carts when not in the line of sight of staff, as observed on two units. RNs admitted to leaving carts unlocked, which contained various medications, including antidepressants and insulin syringes. The DON and other RNs confirmed that carts should be locked when unattended.
The facility failed to report abuse investigation results within the required five working days for two residents. One resident reported being roughly handled by a CNA, and although the initial report was timely, the final report was delayed due to waiting for an external investigation. Another resident was involved in an incident of yelling profanities at a CNA, but there was no evidence of a completed five-day investigation report. The facility did not adhere to its policy of timely reporting, resulting in a deficiency.
A resident with a history of Parkinson's disease and other conditions reported being slapped by a CNA. The facility's investigation was incomplete, as not all relevant staff and residents were interviewed, and non-interviewable residents were not assessed for abuse signs. This led to a deficiency finding.
Expired Food and Improper Labeling of Opened Supplement Drink
Penalty
Summary
During a kitchen inspection, surveyors observed a one-gallon container of lemon juice stored in the kitchen refrigerator that was labeled with an expiration date that had already passed. The container was half full and had not been discarded as required by facility policy, which mandates that expired foods are not to be used in food production or served to residents. The kitchen manager acknowledged the oversight when questioned and confirmed that the expired product should have been removed from storage. Additionally, in a resident-accessible refrigerator on the fourth floor, surveyors found an opened supplement drink that was not labeled with the date it was opened. When asked, a registered nurse confirmed that the supplement should have been labeled with the opened-on date in accordance with facility procedures. These findings indicate that staff did not consistently follow established protocols for food labeling and storage.
Discharge Notice Lacked Effective Date for Hospital Transfer
Penalty
Summary
The facility failed to include the effective date of discharge on the discharge notice for one resident who was transferred to an acute care hospital. The resident had been admitted for physical and occupational therapy with primary diagnoses of pneumonia and Parkinson's disease, and was transferred to the hospital three days later due to respiratory failure secondary to recurrent aspiration pneumonia. Upon review of the discharge and transfer notice, as well as email documentation sent to the Long-Term Care Ombudsman, it was found that the notice provided to both the resident's representative and the Ombudsman did not specify the date of transfer. The Social Services Director confirmed during an interview that the effective discharge date was left blank on the notice.
Failure to Implement and Document Care Plan Interventions for Transfers and Oxygen Therapy
Penalty
Summary
A deficiency was identified when a Certified Nurses Aide (CNA) transferred a resident from bed to wheelchair using a mechanical lift without the required assistance of a second staff member. The CNA stated she performed the transfer alone because she felt capable and the resident trusted her, despite facility policy and the resident's care plan specifying that two staff are required for mechanical lift transfers. The Head Nurse confirmed that this protocol is in place for resident safety and is clearly documented in the care plan accessible to all staff. Additionally, another resident receiving hospice services and with a physician's order for oxygen use as needed did not have any interventions related to oxygen therapy documented in her care plan. The Director of Nursing reviewed the care plan and confirmed the absence of any mention of oxygen use, despite the resident having an active order for titrated oxygen per nasal cannula as needed. The facility's policy on oxygen administration requires review of the care plan for special needs, which was not reflected in the resident's documentation.
Mechanical Lift Transfer Performed Without Required Two-Person Assistance
Penalty
Summary
A deficiency occurred when a certified nurse's aide (CNA) transferred a resident from bed to wheelchair using a mechanical lift without the required assistance of a second staff member. The CNA performed the transfer alone, stating she felt capable and that the resident trusted her to do so. However, both a registered nurse and the head nurse confirmed that facility policy mandates two staff members for all mechanical lift transfers to ensure resident safety. Review of the facility's policy and training materials further confirmed that at least two nursing assistants are required for such transfers, and the CNA had completed relevant training. The incident was observed directly by surveyors and confirmed through staff interviews and record review.
Failure to Label Oxygen Tubing with Initiation Date
Penalty
Summary
A deficiency was identified when a resident's oxygen concentrator tubing was observed on two separate occasions without a label indicating the date of initiation. The tubing, connected to the oxygen concentrator in the resident's room, lacked documentation of when it was first used. During an interview, the head nurse confirmed that the oxygen tubing should be labeled with the date it was started. The DON also verified that the resident had an order for titrated oxygen via nasal cannula as needed and acknowledged that the tubing must be labeled with the initiation date. These findings were based on direct observation and staff interviews.
Expired Flu Vaccine Not Discarded from Medication Refrigerator
Penalty
Summary
Surveyors observed that two vials of expired influenza vaccine, dated 06/2025, were still stored in the medication refrigerator on Young 4 during a check with an RN. The RN acknowledged that the expired vaccines should have been discarded the previous month for safety reasons. An interview with the Head Nurse confirmed that expired medications must be discarded to ensure resident safety and drug efficacy. Review of the facility's Storage of Medication policy indicated that outdated, contaminated, discontinued, or deteriorated medications are to be immediately removed from stock and disposed of according to established procedures. The failure to remove and discard the expired flu vaccines was directly observed and confirmed by staff.
Ineffective QAPI Program in Abuse Reporting and Investigation
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program, specifically in the area of reporting and investigating alleged abuse. This deficiency was identified through interviews, record reviews, and facility document reviews. The facility had been cited for deficiencies F609 and F610 in consecutive years, indicating a recurring issue with the same concerns. The QAPI plan for 2023-2024 outlined responsibilities for reviewing quality improvement reports and developing corrective action plans, but it did not include a Performance Improvement Project (PIP) for abuse reporting and investigating. Interviews with the Director of Nursing (DON) and the Quality Assurance (QA) Coordinator revealed that while abuse allegations were discussed during QAPI meetings, there was no discussion on whether investigations were completed according to the facility's abuse policy. The QA Coordinator acknowledged that the QAPI plan was ineffective, as evidenced by repeated citations for the same issues. The lack of a specific PIP for abuse reporting and investigating contributed to the facility's failure to implement and maintain corrective actions, potentially affecting all residents in the facility.
Failure to Refer Residents for PASARR Evaluation
Penalty
Summary
The facility failed to refer residents with newly evident or possible serious mental disorders to the state-designated mental health or intellectual disability authority for review, affecting two residents. Resident #9 was admitted with a medical history that later included a diagnosis of psychotic disorder, which was not present in the initial PASARR Level I Screen. Despite the diagnosis, there was no evidence of a referral to the appropriate state authority. Similarly, Resident #39 was admitted with a medical history that later included diagnoses of delusional disorders and paranoid personality disorder, which were not identified in the initial PASARR Level I Screen. Again, no referral was made to the state authority following these diagnoses. The facility's policy required that social services be contacted for assistance with Level II evaluations and for any significant mood or behavior changes. However, the facility did not update Level I PASARRs after the residents had been admitted, as confirmed by the Director of Nursing. This oversight led to the failure to initiate necessary Level II evaluations and referrals for residents with significant mental health changes, as required by the facility's policy and state regulations.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that medication carts were locked when not within the line of sight of facility staff, as required by their policy. During an observation, a medication cart on unit Young 4 was found unlocked between two rooms, with no staff present in the hallway. RN #2 acknowledged that the cart should have been locked as it was out of her line of sight. The cart contained various medications, including lisinopril, metoprolol, trazodone, Remeron, Coumadin, Buspar, and insulin syringes. A similar incident occurred on unit Young 5, where another medication cart was found unlocked between two rooms. RN #3 admitted to leaving the cart unlocked in a rush to administer medications, acknowledging that it should have been locked. This cart contained medications such as citalopram, Depakote, Seroquel, metoprolol tartrate, levetiracetam liquid, and insulin syringes. Interviews with the Director of Nursing and other RNs confirmed the expectation that medication carts should be locked when unattended.
Failure to Timely Report Abuse Investigation Results
Penalty
Summary
The facility failed to report the results of abuse investigations within the required five working days to the state survey agency for two residents. The first case involved a resident with a history of Parkinson's disease, multiple sclerosis, and other conditions, who reported being roughly handled by a CNA. The initial report was made within the required two-hour window, but the final report was delayed until nearly two months later due to waiting for an external investigation report. The Director of Nursing (DON) acknowledged the delay and stated that the expectation was to complete and submit the investigation within the five-day timeframe. In the second case, a resident with quadriplegia and other medical conditions was involved in an incident where they were reportedly yelling profanities at a CNA. The initial report was submitted, but there was no evidence that the five-day investigation report was completed and submitted to the state agency. Interviews with staff, including the DON and a social worker, confirmed that the DON was responsible for reporting and investigating such incidents, but the required documentation was not provided. The facility's policy required that abuse allegations be reported to state agencies within two hours and that a final report be submitted within five working days. However, in both cases, the facility did not adhere to this policy, resulting in a deficiency. The DON and other staff members were aware of the reporting requirements, but the necessary follow-up actions were not completed in a timely manner, leading to a failure in compliance with state regulations.
Incomplete Investigation of Abuse Allegation
Penalty
Summary
The facility failed to provide evidence of a thorough investigation into an allegation of abuse involving a resident. The resident, who had a medical history of Parkinson's disease, multiple sclerosis, COPD, and visual hallucinations, reported being slapped on the right upper back by a CNA approximately 15 times. The incident was reported to have occurred around 2:00 PM, but the resident did not inform the day shift staff at the time. The facility's policy required a thorough investigation, including interviews with all relevant staff and residents, but this was not fully executed. The investigation documentation showed that interviews and statements were obtained from the accused CNA, two RNs, and two residents. However, there was no evidence that the facility interviewed or obtained statements from other staff members present during the alleged incident, including three other CNAs, an RN, and an LPN. Additionally, the facility did not provide evidence of interviews with other residents or assessments of non-interviewable residents for signs of abuse, as required by their policy. Interviews with facility staff, including the DON and the Administrator, revealed that the investigation process was incomplete. The DON admitted that they did not assess non-interviewable residents for signs of abuse, and the Administrator was unsure if all necessary interviews were conducted. This lack of thorough investigation and documentation led to the deficiency identified by the surveyors.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Honolulu
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hi'olani Care Center At Kahala Nui | 1.4 mi | ★★★★★ | 0 | 0 |
| Maunalani Nursing And Rehabilitation Center | 1.8 mi | ★★★★★ | 2 | 0 |
| Palolo Chinese Home | 2.2 mi | ★★★★★ | 4 | 0 |
| Hale Ola Kino By Arcadia | 2.4 mi | ★★★★★ | 1 | 0 |
| Oahu Care Facility | 2.5 mi | ★★★★★ | 15 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.