Champions Healthcare at Willowbrook
13500 Breton Ridge, Houston, TX 77070 · Harris County · 98 certified beds · avg 83 residents/day · certified since Sep 15, 2009
Abuse citation flag (CMS)
Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, facility-wide · Feb 25, 2025 · F-0584 · triggered by a complaint
The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Why it matters: An unsafe or unclean environment affects residents' health, comfort, and dignity every single day.
Severity (L): A life-threatening or extremely dangerous situation existed throughout the facility. The single most serious citation CMS can issue.
Corrected: Mar 20, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Apr 23, 2026 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Apr 28, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Apr 23, 2026 · F-0677
The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
Why it matters: Residents who don't get this help can suffer poor hygiene, skin breakdown, weight loss, and a loss of dignity.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Apr 28, 2026 (Deficient, Provider has date of correction)
All citations in the current public record (18)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Apr 23, 2026 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Apr 23, 2026 | ▲ G · Actual harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Apr 23, 2026 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Apr 23, 2026 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Apr 23, 2026 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Apr 23, 2026 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Apr 23, 2026 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Mar 17, 2026 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Dec 9, 2025 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint |
| Dec 9, 2025 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Dec 9, 2025 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Feb 25, 2025 | ▲ L · Immediate jeopardy, facility-wide | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Aug 14, 2024 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Jan 12, 2024 | E · Potential for harm, repeated | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. |
| Jan 12, 2024 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint |
| Jan 12, 2024 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Jan 12, 2024 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Jan 12, 2024 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (1 → 7).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2024 | 6 | 0 | E |
| 2025 | 4 | 1 | L ▲ |
| 2026 | 8 | 2 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $44,335.
| Date | Type | Amount / length |
|---|---|---|
| Apr 23, 2026 | Fine | $13,065 |
| Feb 14, 2025 | Fine | $31,270 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Texas avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.72 | 3.46 | 3.95 | top 24% in Texas; bottom 48% in the U.S. |
| Registered Nurse hours | 0.83 | 0.44 | 0.69 | top 6% in Texas; top 25% in the U.S. |
| Weekend total nurse staffing | 3.19 | 3.04 | 3.50 | top 29% in Texas; bottom 41% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.44 | 0.34 | 0.48 | top 20% in Texas; top 41% in the U.S. |
| Total nursing staff turnover (%) | 51.9 | 55.3 | 45.8 | top 49% in Texas; bottom 32% in the U.S. |
| RN turnover (%) | 58.3 | 54.6 | 42.9 | bottom 43% in Texas; bottom 24% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.52, RN 0.79, weekend 3.02. Staffing rating: 3/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 3/5 · short-stay residents: 4/5
Who owns this facility
For profit - Individual
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Oakbend Medical Center | Organization | 5% or Greater Direct Ownership Interest | 100% | 11/01/2023 |
| Agana, Benjamin | Individual | Managing Control - Governing Body | NOT APPLICABLE | 03/01/2025 |
| Agana, Benjamin | Individual | Operational/Managerial Control | NOT APPLICABLE | 03/01/2025 |
| Agana, Benjamin | Individual | ADP of the SNF | NOT APPLICABLE | 03/01/2025 |
| Burnam, Soon | Individual | Corporate Officer | NOT APPLICABLE | 11/01/2023 |
| Eapen, Sheila | Individual | Managing Control - Governing Body | NOT APPLICABLE | 11/01/2023 |
| Eapen, Sheila | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/01/2023 |
| Eapen, Sheila | Individual | ADP of the SNF | NOT APPLICABLE | 11/01/2023 |
| Ensign Services INC | Organization | ADP of the SNF | NOT APPLICABLE | 08/21/2023 |
| Freudenberger, Joseph | Individual | Corporate Officer | NOT APPLICABLE | 11/01/2023 |
| Holman Health Holdings LLC | Organization | ADP of the SNF | NOT APPLICABLE | 11/01/2023 |
| Keetch, Chad | Individual | Corporate Officer | NOT APPLICABLE | 03/01/2011 |
| Marshall Lake Healthcare LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 11/01/2023 |
| Marshall Lake Healthcare LLC | Organization | ADP of the SNF | NOT APPLICABLE | 10/17/2025 |
| Standard Bearer Healthcare Op, LP | Organization | ADP of the SNF | NOT APPLICABLE | 11/01/2023 |
| The Ensign Group INC | Organization | ADP of the SNF | NOT APPLICABLE | 11/01/2023 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "How do you keep residents' medical records accurate, complete, and secure?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Misty Willow Healthcare and Rehabilitation Center | 1.0 mi | Houston, TX | ★☆☆☆☆ | 1/5 | abuseSFF |
| North Houston Transitional Care | 1.3 mi | Houston, TX | ★★★☆☆ | 3/5 | |
| Fallbrook Rehabilitation and Care Center | 3.8 mi | Houston, TX | ★☆☆☆☆ | 1/5 | SFF |
| Park Manor of Cyfair | 3.8 mi | Houston, TX | ★★★★★ | 5/5 | |
| Legend Oaks Healthcare and Rehabilitation Center - | 4.6 mi | Houston, TX | ★★☆☆☆ | 2/5 | |
| Villa Toscana at Cypress Woods | 5.0 mi | Houston, TX | ★☆☆☆☆ | 2/5 | |
| Cypress Creek Rehabilitation and Healthcare Center | 5.2 mi | Cypress, TX | ★★☆☆☆ | 3/5 | |
| Paradigm at Woodwind Lakes | 6.3 mi | Houston, TX | —/5 | SFF | |
| Eagle Crest Rapid Recovery | 6.5 mi | Houston, TX | ★☆☆☆☆ | 1/5 | abuse |
| Avir at Veterans Memorial | 6.8 mi | Houston, TX | ★☆☆☆☆ | 1/5 | abuse |
| Paradigm Northwest | 7.0 mi | Houston, TX | ★☆☆☆☆ | 1/5 | |
| Cypress Pointe Health & Wellness | 7.0 mi | Houston, TX | ★★★☆☆ | 3/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 676236.