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 05/11/2023
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)
A0749 INFECTION CONTROL PROGRAM
CFR(s): 482.42(a)(1)

The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings;


This STANDARD is not met as evidenced by:
Based on observation the hospital failed to ensure 5 of 5 patient rooms including shower areas (rooms 151, 120, 106, 102, and 101)were maintained in a manner to ensure cleanability and prevent contamination. During initial tour of the patient care areas on 05/08/23/in the presence of facility Staff #7 and 3 , the following was observed: Room 151 "Patient Shower Room" was being used to bathe multiple patients rather than showers in patient rooms. The following was observed: The surface of the interior wall of the shower was chipped, having multiple round holes and indentations throughout the shower enclosure and a section of the lower molding, approximately 3' in length, appeared to have broken off and was missing. A build up of a black substance having the appearance of mold or mildew was observed along the bottom edges of the shower entrance and along the lower molding and interior of the shower enclosure. There was a horizontal silver grab bar mounted to the interior of the shower wall that had a used, wet wash cloth wadded up and tucked in between the railing and the wall, and white plastic cup was sitting on the railing. Room 120 "Patient Shower" was observed to have chipped, multiple round holes and indentations throughout the shower enclosure. The interior drain and interior of the shower had a build up of a black substance with the appearance of mold or mildew. The exterior of the shower entrance had a build up of a black substance throughout the grout/seal located along the floor edge that had the appearance of mold or mildew. The horizontal silver grab bar had areas of rust. The following was observed in Patient Room 106's bath and shower area: the interior of the shower had a build up of a black substance along the grout that had the appearance of mold or mildew. There was grafitti writing in various places on the of the bathroom area that included "M.O.B", "KILLZ", "Brooke was here XOXO", and "So was (illegible)". The round, silver plates located on the wall under the patient sink had a build up of red substance with the appearance of rust. To the right of the sink, connecting the sink to the wall, was a small counter surface area that had chipped edges exposing what appeared to be particle board that could not be sanitized. There was also a build up of a black substance and dirt/debris along the corners of the counter surface. There were personal toiletries including a comb, toothbrush, small tube of toothpaste, two small bottles of liquid personal hygiene materials that included mouthwash. The following was observed in Patient Room 102, the mattress had several rips and tears along its surface preventing the mattress from being able to be sanitized. The baseboard molding had been removed from the base of each wall, leaving chipped paint and exposed sheetrock that could not be sanitized. The ceiling vents had a build up of a reddish material with the appearance of rust and an accumulation of dust. The bathroom of Patient Room 101 was observed the ceiling vents had a build up of a reddish material with the appearance of rust and an accumulation of dust. The commode, behind the seat at the base of the tank, along the seam, had a build up of a reddish material with the appearance of rust. Each of these observations of environmental issues posed issues of potential contamination.