Cycle 1
Health 2025-02-25 · Fire 2025-02-25
4 health deficiencies
Top issue: Resident Rights (2 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Houston, TX
Champions Healthcare At Willowbrook
2-star overall rating with 2-star inspections with $31,270 in total fines with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
13500 Breton Ridge, Houston, TX
(281) 807-4744
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
98
Certified beds
Average residents
84
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
2009-09-15
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.53
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.04
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.85
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.42
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.57
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.91
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.30
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.16
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.55
CMS adjusted RN staffing hours
Adjusted total hours
3.55
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
60%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,936
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.24
Composite VBP score used to determine payment impact.
Payment multiplier
0.9837
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.30
Baseline 25.80% · Performance 20.71% · Measure score 5.30 · Achievement 1.55 · Improvement 5.30
Healthcare-associated infections
0
Baseline 7.75% · Performance 8.50% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Baseline 79.09% · Performance 80.25% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
4.80
Baseline 4.45 hours · Performance 4.44 hours · Measure score 4.80 · Achievement 4.80 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.11% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 159 · Observed rate 11.95% · Lower 95% interval 8.17% |
| Discharge to community | 52.95% |
50.57%
2.4 pts better
|
No Different than the National Rate · Eligible stays 164 · Observed rate 46.34% · Lower 95% interval 46.61% |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 17.24% |
95.27%
78 pts worse
|
Numerator 20 · Denominator 116 |
| Falls with major injury | 2.59% |
0.77%
1.8 pts worse
|
Numerator 3 · Denominator 116 |
| Discharge self-care score | 49.09% |
53.69%
4.6 pts worse
|
Numerator 27 · Denominator 55 |
| Discharge mobility score | 43.64% |
50.94%
7.3 pts worse
|
Numerator 24 · Denominator 55 |
| Pressure ulcers or injuries, new or worsened | 2.59% |
2.29%
0.3 pts worse
|
Numerator 3 · Denominator 116 · Adjusted rate 2.14% |
| Healthcare-associated infections requiring hospitalization | 8.5% |
7.12%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 82 · Observed rate 12.2% · Lower 95% interval 5.53% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 119 |
| Staff flu vaccination coverage | 18.86% |
42%
23.1 pts worse
|
Numerator 33 · Denominator 175 |
| Discharge function score | 58.18% |
56.45%
1.7 pts better
|
Numerator 32 · Denominator 55 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 45 · Denominator 45 |
| Transfer of health information to patient | 96.55% |
96.28%
0.3 pts better
|
Numerator 56 · Denominator 58 |
| Resident COVID-19 vaccinations up to date | 7.79% |
25.2%
17.4 pts worse
|
Numerator 6 · Denominator 77 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.3% |
97.9%
0.4 pts better
|
95.5%
2.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.8% |
3.3%
1.5 pts worse
|
3.3%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 1.8% · Q3 7.1% · Q4 7.5% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.2% |
2.7%
0.5 pts worse
|
11.4%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 6.1% · Q3 2.0% · Q4 2.1% · 4Q avg 3.2% |
| Percentage of long-stay residents who lose too much weight | 3.2% |
3.3%
0.1 pts better
|
5.4%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 3.9% · Q3 3.9% · Q4 2.2% · 4Q avg 3.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.4% |
18.9%
4.5 pts better
|
19.6%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 20.8% · Q3 13.5% · Q4 4.3% · 4Q avg 14.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.5% |
10.8%
2.3 pts better
|
16.7%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 5.4% · Q3 15.4% · Q4 5.4% · 4Q avg 8.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 19.6% |
15.4%
4.2 pts worse
|
16.3%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 19.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.7% |
16.1%
4.6 pts worse
|
14.9%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.0% · Q2 31.1% · Q3 11.4% · Q4 17.9% · 4Q avg 20.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
0.5%
0.2 pts worse
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 0.0% · Q4 1.3% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.5% |
15.0%
0.5 pts worse
|
19.8%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.5% · Q2 14.6% · Q3 9.4% · Q4 20.4% · 4Q avg 15.5% |
| Percentage of long-stay residents with pressure ulcers | 9.3% |
4.2%
5.1 pts worse
|
5.1%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 17.0% · Q3 9.3% · Q4 5.4% · 4Q avg 9.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.1% |
89.7%
5.4 pts better
|
81.7%
13.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.8% · Q2 98.6% · Q3 97.7% · Q4 85.2% · 4Q avg 95.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.3% |
12.0%
0.7 pts better
|
12.0%
0.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.3% · Observed 11.9% · Expected 11.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.5%
1.1 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.5% · Q3 0.5% · Q4 0.6% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.9% |
88.0%
7.9 pts better
|
79.7%
16.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.5% |
25.9%
2.6 pts worse
|
23.9%
4.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.5% · Observed 29.4% · Expected 24.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-12 · Fire 2024-01-12
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2022-12-01 · Fire 2022-12-01
5 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-25
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-02-21
F · Potential for more than minimal harm
2024-01-12
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-01-12
F · Potential for more than minimal harm
2024-01-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-01-16
F · Potential for more than minimal harm
2024-01-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-01-12
F · Potential for more than minimal harm
2024-01-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-01-12
E · Potential for more than minimal harm
2024-01-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-01-16
D · Potential for more than minimal harm
2024-01-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-01-12
D · Potential for more than minimal harm
2024-01-12
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-01-16
F · Potential for more than minimal harm
2022-12-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-12-30
D · Potential for more than minimal harm
2022-12-01
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-12-16
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-09
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-12-10
E · Potential for more than minimal harm
2025-12-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-10
D · Potential for more than minimal harm
2025-12-09
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-12-10
L · Immediate jeopardy
2025-02-25
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2025-03-20
D · Potential for more than minimal harm
2024-08-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-08-16
E · Potential for more than minimal harm
2024-01-12
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-01-16
E · Potential for more than minimal harm
2024-01-12
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-01-15
D · Potential for more than minimal harm
2024-01-12
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-01-15
D · Potential for more than minimal harm
2024-01-12
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-01-15
D · Potential for more than minimal harm
2024-01-12
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-01-15
E · Potential for more than minimal harm
2023-07-17
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-08-11
F · Potential for more than minimal harm
2022-12-01
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-12-16
D · Potential for more than minimal harm
2022-12-01
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2022-12-16
D · Potential for more than minimal harm
2022-12-01
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-12-16
D · Potential for more than minimal harm
2022-12-01
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-12-16
Penalties and ownership
What sits behind the stars
$31,270
2025-02-14
Fine
Fine · fine $31,270
Fine
Ownership
Oakbend Medical Center
5% Or Greater Direct Ownership Interest · Organization
Agana, Benjamin
Operational/Managerial Control · Individual
Burnam, Soon
Corporate Officer · Individual
Eapen, Sheila
Operational/Managerial Control · Individual
Freudenberger, Joseph
Corporate Officer · Individual
Keetch, Chad
Corporate Officer · Individual
Marshall Lake Healthcare LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Misty Willow Healthcare and Rehabilitation Center
Houston, TX
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $46,677 in total fines with 15 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
North Houston Transitional Care
Houston, TX
3-star overall rating with 3-star inspections with $11,508 in total fines with 3 fire-safety deficiencies in the latest cycle
#3
Fallbrook Rehabiliation and Care Center
Houston, TX
1-star overall rating with 1-star inspections with $173,479 in total fines with 24 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
Jump out