Inspection visit
Health inspection
5 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 5 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to develop and implement a comprehensive person-centered
care plan that includes measurable objectives and time frames to meet a resident's medical and nursing
needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and
psychosocial well-being for 1 of 8 residents, Resident #8, reviewed for care plans in that:
-Resident #8's code status (full code) was not care planned.
This failure could place residents in the facility at risk of not being provided with the necessary care or
services and having personalized plans developed to address their specific needs.
The findings:
Record review of Resident #8's Face Sheet reflected a [AGE] year-old female, with an original admission
date of 12/26/2023. Diagnoses included COPD (chronic obstruction, pulmonary disease), Dementia
(Decline in cognitive abilities that impacts a person's ability to perform everyday activities), bipolar disorder
(periods of depression and periods of abnormally elevated mood), Anxiety (An unpleasant state of inner
turmoil and includes feelings of dread over anticipated events) Depression (Mental state of low mood), and
PTSD (post-traumatic stress disorder).
Record review of Resident #8's MDS dated [DATE] reflected a BIMS score of 15 (Cognition Intact).
Record review of Resident #8's physician orders dated 12/26/2023 reflected full code.
Record review of Resident #8's care plan dated 12/26/2023 reflected no code status on 1/9/2024 when
reviewed.
Interview on 01/12/24 at 10:45 AM with the DON stated the MDS coordinator handles all care plans after
initial care plan had been completed by nurses. The DON stated Resident #8's code status should be
updated and reflected in the care plan and to follow Resident #8's wishes. The DON stated possible
negative outcomes for Resident #8 could lead to not implementing the correct code status if an emergency
with Resident #8 occurred.
Interview on 01/12/24 at 01:32 PM with the MDS Resource stated initial care plans were done by nurses
and unsure which nurse completed the initial care plan and why Resident #8's code status was missed. The
MDS Resource stated she was going through recent resident admission records that needed to be updated
or incomplete and saw that Resident # 8's code status was not updated and corrected the
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 10
Event ID:
676236
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676236
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Champions Healthcare at Willowbrook
13500 Breton Ridge
Houston, TX 77070
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
care plan on 1/11/2024. The MDS Resource stated she did not have an answer on why it was missed and
stated that there would be no negative outcome for Resident #8 since the code status was in physician
orders and on Resident #8's main chart. The MDS Resource stated nurses know where to look in the
computer system for code status if needed.
Residents Affected - Few
Record review of the Care Plans Policy dated 10/2010 stated;
An individualized comprehensive care plan that includes measurable objectives and timetables to meet the
residents. Medical, nursing, mental and psychological needs is developed for each resident.
7. The resident's comprehensive care plan is developed within seven days of the completion of the
Residence Comprehensive Assessment MDS.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676236
If continuation sheet
Page 2 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676236
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Champions Healthcare at Willowbrook
13500 Breton Ridge
Houston, TX 77070
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0679
Provide activities to meet all resident's needs.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews, and record reviews, the facility failed to provide, based on the comprehensive
assessment and care plan and the preferences of each resident, an ongoing program to support residents
in their choice of activities for 3 of 3 residents (Resident #37, #14, #16) reviewed for activities.
Residents Affected - Some
The facility failed to provide Residents #37, #16 and' #14 with activities designed to meet their interests and
promote physical, mental, and psychosocial well-being.
This failure could affect residents at the facility who require assistance to activities to decline in mental
acuity due to lack of stimulation, boredom, and depression.
The findings included:
Record review of Resident #37s face sheet accessed 1/12/24 indicated she was an 86 y/o female, admitted
on [DATE] with a diagnosis dated 1/3/24 for failure to thrive and CVA right hemiparesis.
Record review of Resident #37s MDS dated [DATE] indicated she had a BIMS score of 15 which indicated
intact cognition.
Observation of Resident #37 on 1/10/24 at 10:53 AM revealed her lying in bed with a wheelchair within
reach. Two of her family members were present in the room visiting with her.
During an interview with Resident #37 on 1/10/24 at 10:53 AM she said she was not aware of any activities
offered at the facility. When asked what she did for fun she said, not a damn thing.
In an interview on 1/10/24 at 10:53 AM a Family Member said he would have liked the facility to provide
activities to Resident #37 but was unaware any were available.
Record review of Resident #16's face sheet indicated he was an [AGE] year-old male admitted on [DATE]
with a diagnosis of a fractured leg.
Record review of Resident # 16's MDS dated [DATE] indicated he had a BIMS score of 15, which indicated
intact cognition.
During an interview with Resident #16 on 1/12/24 at 11:01 AM he said that usually, he just sits around in
the hallways or in the dining room or watches TV in his room. Resident #16 said when you get admitted
here, they make it seem like it's going to be busy all the time and there's always going to be stuff to do but
there is never anything to do. There is no bingo. There are no games. Resident #16 said no one asked him
if he wanted to do activities, and the only people that come to his room were there to give medication or
food.
Record review of Resident #14s face sheet indicated she was a [AGE] year-old female admitted [DATE]
with a diagnosis of acute respiratory failure.
Record review of Resident #14's MDS dated [DATE] indicated she had a BIMS score of 15, which indicated
intact cognition.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676236
If continuation sheet
Page 3 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676236
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Champions Healthcare at Willowbrook
13500 Breton Ridge
Houston, TX 77070
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0679
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
During an interview with Resident # 14 on 1/12/2024 at 11:12 AM she said she did not do anything for fun.
Resident #14 said nothing that was on the activity calendar was what they did every day. She said she
would like to partake in a reading club, or bingo.
During an interview with the administrator on 1/10/24 at 2:00 PM, she said she did not have an activity
director. She said the facility had not had an activity director since they opened on November 1st, 2023.
She said she hired an activity assistant that worked full time and she left soon after Christmas. The
administrator said she expected a new activity director to begin working the following week. The
administrator said the administrator in training has helped once per week. The physical therapy has been
helping once or twice per week with group activities. She said most of the Medicare patients that were not
bedridden were taken out. Most of the Medicare patient were given TVs and that was the main source of
activity for patients that don't leave their room.
During an interview with the DON on 1/12/2024 at 10:15 she said people suffer loneliness if they have no
activities and that it was an issue for nurses. The DON said the residents could start having attention
seeking behavior and it could create some mental health issues.
Record review of facility's assessment tool dated November 2023 indicated:
Part 1: Considerations made for determining staffing besides the clinical picture of the patient includes, but
is not limited to, resident preferences with regards to daily schedules, waking, napping, bedtimes, bathing
and activities.
Part 2: Services and Care We Offer Based on our Residents' Needs. 2.1 The general types of care that our
resident population requires and that we provide, and additional considerations relative to the provision of
that care, include the following: Provide opportunities for social activities/life enrichment (individual, small
group, community)
Record review of the facility Resident admission Agreement indicates: As a resident of this nursing facility,
you have the right to self-determination through support of your choice, including the right to choose
activities, interact with members of the community and participate in community activities inside the facility.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676236
If continuation sheet
Page 4 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676236
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Champions Healthcare at Willowbrook
13500 Breton Ridge
Houston, TX 77070
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, record review the facility failed to establish a system of records, receipts, and
disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and account for all
controlled drugs for one resident (Resident #99) reviewed for disposition of drugs in a sample of 8
residents.
It was determined the facility failed to provide pharmaceutical services that ensure the accurate
administering of drugs for 1 of 2 medication rooms observed for medications stored and properly labeled.
One of the medication rooms had 2 glucagon pens, used for injection, that were expired. A medication,
Tramadol, did not have a narcotic record amount that matched the quantity on hand.
This failure could place residents at risk of not receiving medications because of drug diversions or
receiving medications that were expired and therefore not producing the desired effect or leading to
infection.
Findings include:
During a record review of the pharmacy destruction records on [DATE] at 10:30 AM for medications being
held for destruction, the Narcotic Record of Resident #99's Tramadol indicated 26 pills and Resident #99's
medication card had 25 pills.
During an interview on [DATE] at 10:30 AM, when asked the facility's process to destroy medications, the
DON said medications that were to be destroyed were kept in the DON's office in a cabinet. The DN said
the office door is locked, and the cabinet is locked. This process was in place at the time of the missing
medication and remained the process at the time of survey. The DON said sign out sheets, which document
how much Tramadol the resident received, when, and by whom and how much Tramadol is left to be
destroyed, are secured to the drug with a rubber band. The sign out sheets are signed by the nursing staff
bringing the medication to the DON's office for storage until disposal and document how much medication
is left for destruction. The DON stated there was no other documentation other than the sign out sheets to
indicate what medications are to be destroyed. The DON said she did not know why the medication card did
not match the reconciliation sheet.
During an interview on [DATE] at 10:15 AM with the DON, she said she did not report the missing
Tramadol. The DON said a discrepancy between the card and the reconciliation sheet could indicate a drug
diversion. The DON said a possible cause of drug diversion needed to be investigated. The DON said she
did not know if drug was given, destroyed (wasted) or diverted. The DON said she did not call the police.
During an observation of 1 of 2 medication rooms on [DATE] at 10:00 AM (2) glucagon single dose injectors
were found to be expired March of 2023.
During an interview on [DATE] at 10:30 AM the DON said the efficacy of an injectable drug may be
insufficient if a medication is expired. The use of an expired injectable medication could lead to infection.
Record review of the storage of medications policy/procedures (MED-PASS Revised [DATE]) read the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676236
If continuation sheet
Page 5 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676236
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Champions Healthcare at Willowbrook
13500 Breton Ridge
Houston, TX 77070
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0755
Level of Harm - Minimal harm
or potential for actual harm
facility shall not use discontinued, outdated or deteriorated drugs or biologicals. All such drugs shall be
returned to the dispensing pharmacy or destroyed.
Record review of the Drug Diversion, Reporting and Response policy and procedure (Nursing Services
Policy and Procedures Revised [DATE]) read,
Residents Affected - Few
Employees are required to report known or suspected incidents of drug diversion by employees,
patients/residents, and visitors.
At each shift change, a physical inventory of all controlled medications is conducted by licensed nurses and
is documented on the controlled substance accountability record.
Any discrepancy is controlled substance medication counts is reported to the director of nursing
immediately.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676236
If continuation sheet
Page 6 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676236
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Champions Healthcare at Willowbrook
13500 Breton Ridge
Houston, TX 77070
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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.
Based on observation, interview, and record review the facility failed to ensure that drugs and biologicals
used in the facility were secured properly for one of one wound care carts (Hall 100 nurse medication cart)
reviewed for drug storage in that:
-Wound Care cart on Hall 100 was left unlocked and unattended. LVN E left medications unsupervised that
were assessable to residents.
This failure could place residents who reside on Hall 100 who receive treatment from the wound care cart
at risk for harm to unauthorized people and place the facility at risk for possible drug diversion.
Findings include:
Observation on 01/11/24 at 09:22 AM revealed the 100-hall wound care cart unlocked and unattended.
Wound Care nurse noted to be in a resident's room getting left over supplies after performing wound care.
There were no residents in the hallway however, there was one nurse (RN A) about 5 feet from the wound
care cart but was unaware the wound care cart was unlocked and did not know where the wound care
nurse was as RN A has just finished assisting a resident in their room. This surveyor was able to open
multiple drawers and pull out a variety of medications and supplies from the wound care cart.
During an observation of a medication pass on 1/10/24 at 10:20 AM, LVN E left a medication unattended
on top of a medication cart and walked away for approximately 5 minutes.
Interview on 01/11/24 at 9:27 AM the wound care nurse stated she normally does not leave the wound care
cart unlocked but got distracted when she went into a resident's room nearby (door closed) to get left over
supplies and forgot to lock the wound care cart. The wound care nurse stated it was important to lock the
wound care cart because anybody who was unauthorized could come along and take supplies or
medication from the wound care cart. The wound care nurse stated last in-service on locking
medication/wound care carts was about 14 days ago.
Interview on 01/11/24 at 11:48 AM the DON stated all medication and wound care carts should be locked
at all times to prevent unauthorized people from having access to the wound care cart medication and
supplies. The DON stated that last in-service on locked medication/wound care carts was about two weeks
ago and charge nurses as well as Administration are responsible for making sure medication/wound care
carts are locked at all times.
During an interview with LVN E on 1/10/24 at 10:30 AM she said she should not have left a medication out
on top of the medication cart unsupervised. She said she was nervous. She said any resident could have
picked it up.
During an interview with the DON on 1/10/24 at 1:00 PM she said she knew that the nurses were not
supposed to leave medications out of the medication cart unattended. The DON said there was a risk that
anyone could come by and take the medication. The DON said LVN E had training yearly with skills check
off and had monthly in-services. The DON said LVN E was up to date with her training. The DON
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676236
If continuation sheet
Page 7 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676236
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Champions Healthcare at Willowbrook
13500 Breton Ridge
Houston, TX 77070
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
said she supervised the training and went around with the nurses once a month and checked the carts and
medication delivery.
Record review of Storage of Medications Policy dated 4/2007 stated;
7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.)
containing drugs and biologicals shall be locked when not in use and trays or carts used to transport such
items shall not be left unattended, if open or otherwise potentially available to others.
Record review of the Charge Nurse Skills Checklist-skilled Nursing form completed by LVN E and signed by
DON dated 11/8/23 indicated satisfactory performance of oral medication administration.
Record review of the Relias training transcript indicated course completion by LVN E of Medication Basics
for Long Term Care Professionals dated 12/9/23.
Record review of the Med-Pass Storage of Medications policy and procedures (revised April 2007) The
facility shall store all drugs and biologicals in a safe, secure, and orderly manner.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676236
If continuation sheet
Page 8 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676236
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Champions Healthcare at Willowbrook
13500 Breton Ridge
Houston, TX 77070
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve
food in accordance with professional standards for food service safety for 1 of 1 facility reviewed for food
storage sanitation in that:
The facility failed to store raw meat properly in the refrigerator. This failure could place residents at risk for
cross-contamination and food-borne illnesses.
This failure could place all residents who received meals at the facility at risk for food borne illness.
Findings included:
Observation on 01/09/2024 at 10:22 am, the Investigator entered the walk-in cooler where the raw meat
was located. A package of raw meat rested on the bottom shelf with a puddle of blood on the floor directly
beneath the sealed package of meat.
Interview on 01/09/24 at 10:22am, the Investigator asked the Dietary Manager how long the blood had
been there, and Dietary Manager responded, To be honest, that has been there for three days. When the
investigator asked the Dietary Manager what the risks and harms were to having blood on the floor in a
walk-in cooler, the Dietary Manager stated that others can slip and fall from the puddle on the floor, other
food items could become contaminated, and that bacteria could be harmful to the dietary staff and the
residents. The Dietary Manager stated that all staff in the kitchen are responsible to maintain cleanliness
and cleaning the kitchen. All Dietary staff is responsible for overseeing the cleanliness of their work area.
The cleanliness of the kitchen is monitored with the kitchen logs they use during their shifts. The Dietary
Manager stated that he is responsible for doing a walk through. Dietary manager stated that meat should
be stored by being properly sealed.
Observation and interview on 1/11/24 at 9:04am, revealed personal drinks, a Ziplock bag of snacks, and a
personal cell phone on the preparation board where the Dietary Staff was preparing vegetables for the
upcoming lunch. The Investigator asked the Dietary Staff and the Dietary Manager who the personal bundle
of items belonged to; the Dietary Staff took ownership of the items. Both the Dietary Staff and the Dietary
Manager stated that the personal items should not be located at the same area.
Record review of the facility's policy on, Personal Items in Kitchen, dated October 2017, revealed:
-It is the policy of this facility that any food or personal items that are brought to the kitchen by staff must be
directed to an area that does not come into contact with the food and the area that is preparing food for the
residents.
-Procedures: .2. Staff need to be aware that if personal items are being placed in areas of the kitchen that
are used for handling the food that is prepared for the residents it is not sanitary and could result in
sickness.
The facility's Resident Census and Conditions of Residents form, dated 09/25/22, revealed 55 residents
received meals at the facility.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676236
If continuation sheet
Page 9 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676236
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Champions Healthcare at Willowbrook
13500 Breton Ridge
Houston, TX 77070
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Record review of the facility's policy Food Receiving & Storage Policy Statement revealed, All food,
chemicals, and supplies should be received and stored in a manner that ensures quality and maximizes
safety of the food served.
Facility's Foods Brought by Family/Visitors policy dated July 2023 reflected:
Residents Affected - Some
Policy Interpretation & Implementation
Nursing home residents risk serious complications from foodborne illness as a result of their compromised
health status. Unsafe food handling practices represent a potential source of pathogen exposure for
residents. Sanitary conditions must be present in health care food service settings to promote safe food
handling. CMS recognizes the U.S. Food and Drug Administration's (FDA) Food Code and the Centers for
Disease Control and Prevention's (CDC) food safety guidance as national standards to procure, store,
prepare, distribute, and serve food in long term care facilities in a safe and sanitary manner.
Contaminated Equipment - Equipment can become contaminated in various ways including, but not limited
to:
o
Poor personal hygiene;
o
Improper sanitation; and
o
Contact with raw food (e.g., poultry, eggs, seafood, and meat).
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676236
If continuation sheet
Page 10 of 10
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Back to topCitations
5 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F679 - Activities
Provide activities to meet all resident's needs.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F761 - Labeling of Drugs and Biologicals
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.
FAQ · About this visit
Common questions about this visit
What happened during the January 12, 2024 survey of CHAMPIONS HEALTHCARE AT WILLOWBROOK?
This was a inspection survey of CHAMPIONS HEALTHCARE AT WILLOWBROOK on January 12, 2024. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at CHAMPIONS HEALTHCARE AT WILLOWBROOK on January 12, 2024?
Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide activities to meet all resident's needs."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.