Federal inspection record · CMS data as of October 1, 2026
Champions Healthcare at Willowbrook
13500 Breton Ridge, Houston, TX · (281) 807-4744
- Cited for abuse (CMS abuse icon)
- Certified beds
- 98
- Residents per day
- 88
- Ownership
- For-Profit
- Chain
- The Ensign Group
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- September 15, 2009
1
How this home got 2 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Texas.
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Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★no change
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
-
Overall
★★★★★2 of 5
Matches the rating CMS publishes on Care Compare.
This home carries CMS's abuse icon, which caps its inspection rating at 2 stars and so its overall rating at 4.
2
Where it sits among Texas homes
Champions Healthcare at Willowbrook carries 118.75 inspection points. That is fewer than 28% of Texas's 1,166 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Texas: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–26 pts
- 4★ 26–51 pts
- 3★ 51–85 pts
- 2★ 85–145.75 pts
- 1★ over 145.75 pts
Bars show every rated home in Texas by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
19 health citations on record since 2024. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (3)
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G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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G
Provide care and assistance to perform activities of daily living for any resident who is unable.
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L
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.
Everything else, by area of care
Pharmacy Service5E
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
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.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
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.
Nutrition and Dietary3E
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Resident Assessment and Care Planning2D
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Infection Control2E
- D
Provide and implement an infection prevention and control program.
- E
Provide and implement an infection prevention and control program.
Quality of Life and Care2E
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- E
Provide activities to meet all resident's needs.
Freedom from Abuse, Neglect, and Exploitation1D
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Resident Rights1D
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspection history
2026-04-23
12 health deficiencies · 3 fire-safety deficiencies
Top issue: Pharmacy Service (3 deficiencies)
2025-02-25
1 health deficiencies · 1 fire-safety deficiencies
Top issue: Resident Rights (1 deficiency)
2024-01-12
6 health deficiencies · 7 fire-safety deficiencies
Top issue: Pharmacy Service (2 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 3 h 24 min of nursing staff time a day, 39 min of it from a registered nurse.
This home
3 h 24 min
Texas average
3 h 25 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 51% of nursing staff and 54% of registered nurses left in the past year, along with 1 administrator.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Fines and payment denials
$39,762 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2026-04-23 | Fine | $8,492 |
| 2025-02-14 | Fine | $31,270 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine1.3 pts better | 97.7% | 96.4% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine7.2 pts worse | 89.8% | 97.0% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury2.8 pts worse | 6.0% | 3.2% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms1.8 pts better | 0.5% | 2.3% | 13.5% |
| Percentage of long-stay residents who lose too much weight1.7 pts worse | 4.6% | 2.9% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication5.6 pts better | 12.2% | 17.8% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication3.5 pts worse | 13.3% | 9.8% | 15.4% |
| Percentage of long-stay residents who were physically restrainedAbout the same | 0.0% | 0.0% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened1.9 pts worse | 14.8% | 12.9% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased0.5 pts worse | 16.3% | 15.8% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder0.5 pts worse | 0.8% | 0.3% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection0.8 pts better | 0.0% | 0.8% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence5.9 pts worse | 18.4% | 12.5% | 18.3% |
| Percentage of long-stay residents with pressure ulcers0.9 pts worse | 4.6% | 3.7% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine31.4 pts worse | 57.3% | 88.7% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit0.4 pts better | 11.8% | 12.2% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication0.2 pts better | 1.2% | 1.4% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine40.3 pts worse | 45.1% | 85.4% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission3.4 pts better | 22.1% | 25.5% | 23.4% |
·
Who owns and runs it
16 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Oakbend Medical Center | 5% Or Greater Direct Ownership Interest · Organization | 100% | 32 facilities |
| Agana, Benjamin | Managing Control - Governing Body · Individual | 0% | 1 facilities |
| Agana, Benjamin | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Agana, Benjamin | Adp Of The SNF · Individual | 0% | 1 facilities |
| Burnam, Soon | Corporate Officer · Individual | 0% | 353 facilities |
| Eapen, Sheila | Managing Control - Governing Body · Individual | 0% | 2 facilities |
| Eapen, Sheila | Operational/Managerial Control · Individual | 0% | 2 facilities |
| Eapen, Sheila | Adp Of The SNF · Individual | 0% | 2 facilities |
| Ensign Services Inc | Adp Of The SNF · Organization | 0% | 299 facilities |
| Freudenberger, Joseph | Corporate Officer · Individual | 0% | 35 facilities |
| Holman Health Holdings LLC | Adp Of The SNF · Organization | 0% | 1 facilities |
| Keetch, Chad | Corporate Officer · Individual | 0% | 301 facilities |
| Marshall Lake Healthcare LLC | Operational/Managerial Control · Organization | 0% | 1 facilities |
| Marshall Lake Healthcare LLC | Adp Of The SNF · Organization | 0% | 1 facilities |
| Standard Bearer Healthcare Op, LP | Adp Of The SNF · Organization | 0% | 78 facilities |
| The Ensign Group Inc | Adp Of The SNF · Organization | 0% | 135 facilities |
·
Fire safety
11 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke6F
- D
Inspect, test, and maintain automatic sprinkler systems.
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
- F
Inspect, test, and maintain automatic sprinkler systems.
- E
Have approved installation, maintenance and testing program for fire alarm systems.
- D
Provide properly protected cooking facilities.
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
Miscellaneous2F
- F
Have restrictions on the use of portable space heaters.
- F
Have simulated fire drills held at unexpected times.
Services1D
- D
Have properly installed electrical wiring and gas equipment.
Egress1F
- F
Install emergency lighting that can last at least 1 1/2 hours.
Gas, Vacuum, and Electrical Systems1F
- F
Have generator or other power source capable of supplying service within 10 seconds.
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Other homes nearby
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★★★★★- Worst citation, 3 yrs
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-
North Houston Transitional Care
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-
Fallbrook Rehabilitation and Care Center
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