Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391

Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 670093 (X3) Date Survey Completed 06/22/2021
Name of Provider or Supplier Aspire Hospital Street Address, City, State 2006 South Loop 336 West, Suite 500, Conroe, TX
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
A0143 PATIENT RIGHTS: PERSONAL PRIVACY
CFR(s): 482.13(c)(1)

The patient has the right to personal privacy.


This STANDARD is not met as evidenced by:
Based on observation, record review, and interview, the facility failed to ensure the personal privacy of patients by posting the full names of 2 of 4 patients (Patient #12 and Patient #13) on the "6/17/2021 Shower List" displayed on a window at the nurse's station. Findings included: Observation of the nurse's station on the adult psychiatric unit on 6/17/2021 at 11:00am showed the "6/17/2021 Shower List had been taped to a widow at the nurse's station. Review of the shower list showed the full names of 2 of 4 patients (Patient #12 and Patient #13). In an interview with Staff A (CNO) on 6/17/2021 at 11:00am, he stated that the full names of the patients should not be on display on this list at the nurse's station for the other patients to see.