Home › Texas › Harris County › Champions Healthcare at Willowbrook
Champions Healthcare at Willowbrook
13500 Breton Ridge, Houston, TX 77070 · CMS Certification Number (CCN) 676236
CMS abuse icon
CMS shows the abuse icon when a nursing home was cited for abuse or neglect at the harm level or above (scope/severity G or higher) on its most recent inspection cycle, or at the potential-harm level (D or higher) on both of its two most recent cycles. CMS data dictionary
At a glance
- CMS overall rating
- ★★☆☆☆ 2 of 5
- Health inspection citations
- 19 in the last 3 inspection cycles (1 immediate jeopardy, 2 actual harm, 9 from complaints)
- Fire safety citations
- 11
- Fines (last 3 years)
- 2 fines, total $44,335
- Payment denials
- 0
- Most recent standard inspection
- April 23, 2026
- Official record
- Medicare Care Compare page for this facility
Source: CMS Nursing Home Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
CMS star ratings
CMS rates every Medicare- and Medicaid-certified nursing home from 1 to 5 stars. Health inspection stars are relative to other homes in the same state: the top 10% get 5 stars and the bottom 20% get 1 star. CMS says to use the ratings together with other information, including a visit. Technical Users’ Guide
| Rating | This facility | Texas average | U.S. average |
|---|---|---|---|
| Overall | ★★☆☆☆ 2 of 5 | 2.7 | 3 |
| Health inspections | ★★☆☆☆ 2 of 5 | 2.8 | 2.8 |
| Staffing | ★★★☆☆ 3 of 5 | 1.9 | 2.9 |
| Quality measures | ★★★☆☆ 3 of 5 | 3.7 | 3.6 |
| Long-stay quality | ★★★☆☆ 3 of 5 | Not published | Not published |
| Short-stay quality | ★★★★☆ 4 of 5 | Not published | Not published |
Averages: CMS State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Health inspections
| Inspection cycle | Standard survey date | Health citations | From standard survey | From complaints |
|---|---|---|---|---|
| Cycle 1 (most recent) | April 23, 2026 | 12 | 7 | 6 |
| Cycle 2 | February 25, 2025 | 3 | 1 | 3 |
CMS weighted health inspection score: 118.75 (lower is better; it counts citation severity, complaints and repeat revisits). Citations from infection control inspections: Not published. How to read these citations
19 health citations across 7 inspection dates, newest first. The letter is CMS’s scope/severity code: A–C means potential for minimal harm, D–F potential for more than minimal harm, G–I actual harm, and J–L immediate jeopardy.
July 28, 2026: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Complaint | Deficient, Provider has no plan of correction |
April 23, 2026: 7 citations (Standard + Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/28/2026 |
| D | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/28/2026 |
| E | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/28/2026 |
| D | F-0761 | 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. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/28/2026 |
| D | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/28/2026 |
| G | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/28/2026 |
| G | F-0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 04/28/2026 |
March 17, 2026: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 04/15/2026 |
December 9, 2025: 3 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 12/10/2025 |
| E | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 12/10/2025 |
| D | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 12/10/2025 |
February 25, 2025: 1 citation (Standard + Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| L | 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. Resident Rights Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 03/20/2025 |
August 14, 2024: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 08/16/2024 |
January 12, 2024: 5 citations (Standard + Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 01/15/2024 |
| D | F-0761 | 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. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/15/2024 |
| D | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/15/2024 |
| E | F-0679 | Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/16/2024 |
| D | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/15/2024 |
Source: CMS Health Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Fire safety inspections
11 fire safety citations across 3 inspection dates
| Date | Severity | Tag | What was cited | Status |
|---|---|---|---|---|
| 04/23/2026 | D | K-0511 | Have properly installed electrical wiring and gas equipment. Services Deficiencies | Deficient, Provider has date of correction Corrected 05/18/2026 |
| 04/23/2026 | D | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 04/28/2026 |
| 04/23/2026 | D | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 05/14/2026 |
| 02/25/2025 | F | K-0781 | Have restrictions on the use of portable space heaters. Miscellaneous Deficiencies | Deficient, Provider has date of correction Corrected 02/21/2025 |
| 01/12/2024 | F | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 01/12/2024 |
| 01/12/2024 | F | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies | Deficient, Provider has date of correction Corrected 01/12/2024 |
| 01/12/2024 | D | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 01/16/2024 |
| 01/12/2024 | F | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 01/16/2024 |
| 01/12/2024 | E | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 01/16/2024 |
| 01/12/2024 | D | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 01/12/2024 |
| 01/12/2024 | F | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. Egress Deficiencies | Deficient, Provider has date of correction Corrected 01/12/2024 |
Automatic sprinklers in all required areas: Yes. CMS does not count fire safety citations in the health inspection star rating.
Source: CMS Fire Safety Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Penalties
| Date | Type | Fine amount | Payment denial |
|---|---|---|---|
| April 23, 2026 | Fine | $13,065 | — |
| February 14, 2025 | Fine | $31,270 | — |
Source: CMS Penalties: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Staffing
| Measure | This facility | Texas average | U.S. average |
|---|---|---|---|
| Total nurse staff hours per resident per day | 3.52 | 3.39 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.79 | 0.43 | 0.69 |
| LPN/LVN hours per resident per day | 0.91 | Not published | Not published |
| Nurse aide hours per resident per day | 1.82 | Not published | Not published |
| Total nurse staff hours per resident per day, weekends | 3.02 | Not published | Not published |
| RN hours per resident per day, weekends | 0.44 | Not published | Not published |
| Total nursing staff turnover (%) | 51.9 | 55.3 | 45.8 |
| Registered nurse turnover (%) | 58.3 | Not published | Not published |
| Administrators who have left | 0 | Not published | Not published |
Reported hours come from the Payroll-Based Journal (PBJ) staffing data that facilities submit to CMS each quarter.
Source: CMS Provider Information; State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Facility details
- Legal business name
- Oakbend Medical Center
- Ownership type
- For profit - Individual
- Chain
- The Ensign Group (344 facilities)
- Ownership changed in last 12 months
- No
- Certified beds
- 98
- Average residents per day
- 83.1
- Participates in
- Medicare and Medicaid
- Located inside a hospital
- Yes
- Continuing care retirement community
- No
- Resident and family council
- Resident
- First approved for Medicare/Medicaid
- September 15, 2009
- County/parish
- Harris
Source: CMS Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Owners and managers reported to CMS
16 ownership and management records
| Name | Role | Type | Ownership % | Since |
|---|---|---|---|---|
| OAKBEND MEDICAL CENTER | 5% OR GREATER DIRECT OWNERSHIP INTEREST | Organization | 100% | undefined undefined, NaN |
| AGANA, BENJAMIN | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| EAPEN, SHEILA | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| BURNAM, SOON | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| FREUDENBERGER, JOSEPH | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| KEETCH, CHAD | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MARSHALL LAKE HEALTHCARE LLC | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| AGANA, BENJAMIN | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| EAPEN, SHEILA | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| ENSIGN SERVICES INC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| HOLMAN HEALTH HOLDINGS LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| MARSHALL LAKE HEALTHCARE LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| STANDARD BEARER HEALTHCARE OP, LP | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| THE ENSIGN GROUP INC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| AGANA, BENJAMIN | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| EAPEN, SHEILA | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
Source: CMS Ownership: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Check it yourself
- Medicare Care Compare: Champions Healthcare at Willowbrook. Full inspection reports, quality measures and staffing.
- HHSC long-term care complaint portal (TULIP). The state agency also takes nursing home complaints.
- Ask the facility to show you its most recent inspection report and plan of correction.
Page built from CMS data files processed September 1, 2026 (CMS refreshes monthly). Last checked October 26, 2026. Not a ranking or endorsement.