Champions Healthcare At Willowbrook

Penalties

• Apr 23, 2026 — Fine ($13,065)
• Feb 14, 2025 — Fine ($31,270)

Inspection findings

1. Apr 23, 2026 Health · 10 findings
   • Serious Scope/severity G Complaint

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

     Corrected Apr 28, 2026 · CMS health inspection

   • Serious Scope/severity G

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected Apr 28, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Apr 28, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0761 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.

     Corrected Apr 28, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Apr 28, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0842 Resident Assessment and Care Planning Deficiencies

     Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

     Corrected Apr 28, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Apr 28, 2026 · CMS health inspection

   • Not serious Scope/severity D

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected May 14, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0355 Smoke Deficiencies

     Properly select, install, inspect, or maintain portable fire extinguishes.

     Corrected Apr 28, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected May 18, 2026 · CMS fire safety

2. Mar 17, 2026 Health · 1 finding
   • Not serious Scope/severity E Complaint

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Apr 15, 2026 · CMS health inspection

3. Dec 9, 2025 Health · 3 findings
   • Not serious Scope/severity D Complaint

     F0550 Resident Rights Deficiencies

     Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

     Corrected Dec 10, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Dec 10, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Dec 10, 2025 · CMS health inspection

4. Feb 25, 2025 Health · 2 findings
   • Serious Scope/severity L Complaint

     F0584 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.

     Corrected Mar 20, 2025 · CMS health inspection

   • Not serious Scope/severity F

     K0781 Miscellaneous Deficiencies

     Have restrictions on the use of portable space heaters.

     Corrected Feb 21, 2025 · CMS fire safety

5. Aug 14, 2024 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Aug 16, 2024 · CMS health inspection

6. Jan 12, 2024 Health · 12 findings
   • Not serious Scope/severity D

     F0656 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.

     Corrected Jan 15, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0679 Quality of Life and Care Deficiencies

     Provide activities to meet all resident's needs.

     Corrected Jan 16, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Jan 15, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0761 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.

     Corrected Jan 15, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Jan 15, 2024 · CMS health inspection

   • Not serious Scope/severity F

     K0291 Egress Deficiencies

     Install emergency lighting that can last at least 1 1/2 hours.

     Corrected Jan 12, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Jan 12, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Jan 16, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Jan 16, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0355 Smoke Deficiencies

     Properly select, install, inspect, or maintain portable fire extinguishes.

     Corrected Jan 16, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Jan 12, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Jan 12, 2024 · CMS fire safety

Owners and managers (as published by CMS)

• AGANA, BENJAMIN — managing control - governing body, NOT APPLICABLE, since 03/01/2025
• AGANA, BENJAMIN — adp of the snf, NOT APPLICABLE, since 03/01/2025
• AGANA, BENJAMIN — operational/managerial control, NOT APPLICABLE, since 03/01/2025
• BURNAM, SOON — corporate officer, NOT APPLICABLE, since 11/01/2023
• EAPEN, SHEILA — managing control - governing body, NOT APPLICABLE, since 11/01/2023
• EAPEN, SHEILA — adp of the snf, NOT APPLICABLE, since 11/01/2023
• EAPEN, SHEILA — operational/managerial control, NOT APPLICABLE, since 11/01/2023
• FREUDENBERGER, JOSEPH — corporate officer, NOT APPLICABLE, since 11/01/2023
• KEETCH, CHAD — corporate officer, NOT APPLICABLE, since 03/01/2011
• ENSIGN SERVICES INC — adp of the snf, NOT APPLICABLE, since 08/21/2023
• HOLMAN HEALTH HOLDINGS LLC — adp of the snf, NOT APPLICABLE, since 11/01/2023
• MARSHALL LAKE HEALTHCARE LLC — adp of the snf, NOT APPLICABLE, since 10/17/2025
• MARSHALL LAKE HEALTHCARE LLC — operational/managerial control, NOT APPLICABLE, since 11/01/2023
• OAKBEND MEDICAL CENTER — 5% or greater direct ownership interest, 100%, since 11/01/2023
• STANDARD BEARER HEALTHCARE OP, LP — adp of the snf, NOT APPLICABLE, since 11/01/2023
• THE ENSIGN GROUP INC — adp of the snf, NOT APPLICABLE, since 11/01/2023