Calhoun Convalescent Center: Medication Order Failure - SC
The resident, identified in inspection records only as Resident 85, is a man with severe intellectual disabilities, schizophrenia, and anxiety who receives his medications through a surgically implanted stomach tube. On March 21, 2025, he spent a significant portion of a nursing shift yelling in the hallway and at the nursing station. A licensed practical nurse documented the episode in detail: the resident screaming repeatedly, interventions failing one after another, the resident calming only when a nurse sat with him at bedside, then starting up again the moment she left the room. He told his roommate to shut up, the notes said, even though the roommate hadn't made a sound.
The nurse reached Nurse Practitioner 1 by phone. The NP ordered Benadryl 50 mg through the stomach tube every eight hours as needed for 14 days. The nurse documented giving the first dose that evening. She wrote that it flowed through the tube without difficulty and that she would reassess his behavior.
What she did not do was enter the order into the electronic medication administration record.
Federal inspectors arrived on March 24. That afternoon, at around 4:19 PM, Resident 85 was yelling again. The Director of Nursing told inspectors the resident had an order for Benadryl 50 mg for agitation.
About an hour later, at 5:28 PM, Registered Nurse 1 told inspectors she had tried to calm Resident 85 down but had given him nothing for the yelling. When she reviewed the March 21 progress notes with inspectors, she confirmed what they had already found: the verbal order taken by the LPN three days earlier did not appear anywhere in the electronic medication record. No order had been entered. No doses had been given after that first one.
The Director of Nursing reviewed the electronic records herself at 5:07 PM and reached the same conclusion. She called the nurse practitioner at 5:09 PM. The NP confirmed she had placed the order on March 21 and still wanted it in place.
The Director of Nursing told inspectors the order should have been entered as a medication order in the electronic system and administered as prescribed.
The facility's own policy on physician orders states that verbal orders must be transcribed or electronically entered into the medication administration record. The LPN who took the call documented the order in the progress notes and administered one dose. The order went nowhere after that.
What the inspection record does not answer is how many times between March 21 and March 24 Resident 85 was yelling, and how many times nurses checked for available medications and found nothing, or didn't check at all. The progress note from March 21 describes a man who could not be calmed by any intervention other than a nurse physically sitting with him, and who returned to distress the moment she left. The inspection was conducted on March 24. The medication order had been prescribed to run for 14 days.
Federal inspectors cited the failure as causing minimal harm. The citation covered one resident.
Resident 85 was still yelling when inspectors were in the building.
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: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
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Last verified: November 3, 2026 · Our methodology
Calhoun Convalescent Center in Saint Matthews, SC was cited for violations during a health inspection on March 26, 2025.
On March 21, 2025, he spent a significant portion of a nursing shift yelling in the hallway and at the nursing station.
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.