CHAMPIONS HEALTHCARE AT WILLOWBROOK

13500 BRETON RIDGE
HOUSTON, TX, 77070
2818074744
CCN: 676236
2
Overall
2
Health
2
Staffing
3
Quality
ChainTHE ENSIGN GROUP
Special FocusAbuse IconOwnership Changed (12mo)Inspection OverdueOIG ExcludedUnder CIA
OIG Federal Exclusion Matches (2)
This facility's name matches one or more entities on the OIG List of Excluded Individuals/Entities (LEIE). Excluded parties are prohibited from participation in Medicare and Medicaid programs.
NATIONAL SPINE MEDICAL CENTERS
1128b8
Excluded 2005-04-20
UNITED MEMORIAL MEDICAL CENTER
1128b7
Excluded 2023-12-14
Ownership
NameRole%
OAKBEND MEDICAL CENTER5% OR GREATER DIRECT OWNERSHIP INTEREST100%
BURNAM, SOONCORPORATE OFFICERNOT APPLICABLE
FREUDENBERGER, JOSEPHCORPORATE OFFICERNOT APPLICABLE
KEETCH, CHADCORPORATE OFFICERNOT APPLICABLE
EAPEN, SHEILAOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
MARSHALL LAKE HEALTHCARE LLCOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
AGANA, BENJAMINOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
Penalties (1)
DateTypeAmount
2025-02-14Fine$31K
Health Deficiencies (15)
2025-12-09 · Health
E
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
E
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
D
F550 · Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
2025-02-25 · Health
L
F584 · Resident Rights Deficiencies
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.
2024-08-14 · Health
D
F686 · Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
2024-01-12 · Health
E
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
D
F761 · Pharmacy Service Deficiencies
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.
D
F755 · Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
E
F679 · Quality of Life and Care Deficiencies
Provide activities to meet all resident's needs.
D
F656 · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
2023-07-17 · Health
E
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
2022-12-01 · Health
F
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
D
F645 · Resident Assessment and Care Planning Deficiencies
PASARR screening for Mental disorders or Intellectual Disabilities
D
F641 · Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
D
F640 · Resident Assessment and Care Planning Deficiencies
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Staffing
MetricThis FacilityNational Avg
Total Nurse Hrs/Resident/Day
3.42
3.68
RN Hrs/Resident/Day
0.53
0.54
LPN Hrs/Resident/Day
1.04
0.81
CNA Hrs/Resident/Day
1.85
2.33
PT Hrs/Resident/Day
0.16
0.12
Data as of 2026-03-01