Calhoun Convalescent: Shared Blood Sugar Devices - SC
The March 24 incident at Calhoun Convalescent Center began when RN1 couldn't find the individual glucose monitors for two residents. She searched through medication cart drawers and found an unlabeled EvenCare G2 glucometer, which she declared belonged to Resident 86.
After testing Resident 86's blood sugar at 5:20 PM, recording a result of 153, the nurse cleaned the device with an alcohol prep pad. Hours earlier, she had used the same monitor on Resident 168, whose blood sugar measured a dangerous 279 mg/dL at noon.
"I had to do a blood sugar check earlier on R168, around noon," RN1 told inspectors. "I used R86's blood sugar machine for him. I always clean with an alcohol pad, with each person."
The facility's own policy required individual glucometers for each resident. The manufacturer's recommendations for the EvenCare G2 specified cleaning with Medline Micro-Kill Bleach Germicidal Wipes to prevent infectious disease transmission.
But nurses weren't following either standard.
At 5:50 PM, inspectors watched Licensed Practical Nurse 1 place a glucometer into a resident pouch after cleaning it with only an alcohol wipe. "All residents have their own glucometer," she explained, despite evidence to the contrary.
LPN2 described using MicroKill Bleach Wipes for cleaning, even though she also believed each resident had individual devices. The contradiction revealed a facility where policies existed on paper but weren't implemented in practice.
When RN1 opened each medication cart pouch to verify glucometer assignments, the scope of the problem became clear. Residents 168 and 67 had no glucometers in their designated pouches. Both were diabetic patients requiring regular blood sugar monitoring.
Resident 86, whose monitor had been borrowed for another patient, was admitted with Type 2 diabetes, binge eating disorder, and morbid obesity. Her cognitive assessment showed she was mentally intact with a perfect score of 15 out of 15.
Resident 168 had been admitted following surgical amputation. His blood sugar reading of 279 mg/dL represented a dangerously high level that required immediate attention. Like Resident 86, he scored 15 out of 15 on cognitive testing.
Resident 67, also diabetic, had a blood sugar reading of 106 mg/dL recorded that day. His cognitive assessment showed moderate impairment with a score of 12 out of 15. He lived with Type 2 diabetes with hyperglycemia, hypertension, pain, and schizophrenia.
The Director of Nursing knew the correct procedures. During her March 25 interview, she outlined proper glucometer cleaning: wash hands, don gloves, inspect for visible soil, wipe with alcohol, then use EPA-approved germicidal wipes with three minutes of contact time.
"Each patient has their own glucometers," she said. "It is not ok for a nurse to use another resident's glucometer."
She described having extras in the supply room and a system where the Unit Manager audited medication carts every Monday to ensure each resident had their own device. She had stocked at least five backup glucometers.
But the Monday audits had missed the missing devices.
The infection control failures extended beyond shared glucometers. Nurses weren't implementing Enhanced Barrier Precautions for residents who required them. RN2 stated that Resident 188, who had a wound vacuum, wasn't on Enhanced Barrier Precautions despite facility policy requiring them for residents with wounds and indwelling medical devices.
LPN4 confirmed that both Resident 86 and Resident 168 should have had Enhanced Barrier Precaution orders and door signage, but neither did.
The facility's Enhanced Barrier Precaution policy, revised in May 2023, required special precautions for residents with multidrug-resistant organism infections, wounds, or indwelling medical devices like central lines, urinary catheters, feeding tubes, or tracheostomies.
Federal inspectors classified the violations as immediate jeopardy, the most serious level of harm. The shared use of blood glucose monitoring devices between residents created direct risk for transmitting bloodborne pathogens including Hepatitis B, Hepatitis C, and HIV.
On March 26, the facility submitted a removal plan acknowledging the violations. They assessed residents requiring blood glucose monitoring for signs of infection and implemented Enhanced Barrier Precautions for Resident 168.
EPA disinfectant wipes were placed in medication carts. The Director of Nursing completed an audit to verify each diabetic resident had an available glucometer.
The facility committed to reviewing all residents to identify those requiring Enhanced Barrier Precautions, including residents with drug-resistant infections not on transmission precautions, residents with wounds of any type, and residents with indwelling medical devices.
Licensed nurses would receive re-education on proper blood glucose monitoring procedures, including validating the correct glucometer use, locating backup devices, using barriers when placing glucometers in resident rooms, and following the two-step EPA disinfectant cleaning process.
The Director of Nursing planned to observe two nurses for five days to validate proper infection control techniques. She would check daily for five days that EPA disinfectant wipes remained available on medication carts storing glucometers.
Federal inspectors accepted the removal plan at 4:00 PM on March 26.
But for Resident 168, whose blood sugar spiked to 279 while his glucometer sat missing from its designated pouch, the damage was already done. The shared device that tested his blood had been used on another resident hours earlier, cleaned only with an alcohol pad that couldn't eliminate bloodborne pathogens.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Calhoun Convalescent Center from 2025-03-26 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 14, 2026 · Our methodology
Calhoun Convalescent Center in Saint Matthews, SC was cited for violations during a health inspection on March 26, 2025.
The March 24 incident at Calhoun Convalescent Center began when RN1 couldn't find the individual glucose monitors for two residents.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.
Frequently Asked Questions
- What happened at Calhoun Convalescent Center?
- The March 24 incident at Calhoun Convalescent Center began when RN1 couldn't find the individual glucose monitors for two residents.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in Saint Matthews, SC, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from Calhoun Convalescent Center or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 425170.
- Has this facility had violations before?
- To check Calhoun Convalescent Center's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.