Inspection Reports for Traditions of Columbus
4300 WEST GOELLER BLVD, COLUMBUS, IN, 47201
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 24, 2025, found no deficiencies related to the complaint investigated. Earlier inspections showed a generally compliant pattern with multiple complaint investigations resulting in no deficiencies cited. Prior deficiencies included medication management issues, such as a delayed dose reduction for an anticoagulant and a substantiated case of medication misappropriation by a nurse who resigned. There were also past findings related to resident safety, including failure to prevent elopement and infection control practices, but these were followed by corrective actions and subsequent compliance. The overall trend suggests improvement, with recent inspections showing no new deficiencies and prior issues addressed.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
1.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
57% better than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
90 residents
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 0
Date: Jun 24, 2025
Visit Reason
This visit was for the Investigation of Complaint IN00459590.
Complaint Details
Complaint IN00459590 - No deficiencies related to the allegations were cited.
Findings
No deficiencies related to the allegations were cited. Traditions of Columbus was found to be in compliance with 410 IAC 16.2-5 in regard to the Investigation of Complaint IN00459590.
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 0
Date: Apr 1, 2025
Visit Reason
This visit was for the investigation of complaints IN00454905, IN00455710, and IN00455779.
Complaint Details
Complaints IN00454905, IN00455710, and IN00455779 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00454905, IN00455710, and IN00455779 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding these complaints.
Report Facts
Residential Census: 92
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 0
Date: Feb 21, 2025
Visit Reason
This visit was for the investigation of complaints IN00452478 and IN00453872.
Complaint Details
Complaint IN00452478 and Complaint IN00453872 were investigated with no deficiencies cited related to the allegations.
Findings
No deficiencies related to the allegations were cited for either complaint. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the investigation of these complaints.
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 0
Date: Jan 21, 2025
Visit Reason
This visit was for the Investigation of Complaint IN00449890.
Complaint Details
Complaint IN00449890 - No deficiencies related to the allegations were cited.
Findings
No deficiencies related to the allegations were cited. Traditions of Columbus was found to be in compliance with 410 IAC 16.2-5 in regard to the Investigation of Complaints IN00449890.
Inspection Report
Original Licensing
Census: 94
Deficiencies: 0
Date: Dec 5, 2024
Visit Reason
This visit was for a State Residential Licensure Survey conducted on December 4 and 5, 2024.
Findings
Traditions of Columbus was found to be in compliance with 410 IAC 16.2-5 in regard to the State Residential Licensure Survey.
Inspection Report
Complaint Investigation
Census: 95
Deficiencies: 0
Date: Nov 25, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00446644.
Complaint Details
Complaint IN00446644 - No deficiencies related to the allegations were cited.
Findings
No deficiencies related to the allegations were cited. Traditions of Columbus was found to be in compliance with 410 IAC 16.2-5 in regard to the Investigation of Complaints IN00446644.
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 0
Date: Jun 18, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00434278.
Complaint Details
Complaint IN00434278 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations are cited. Traditions of Columbus was found to be in compliance with 410 IAC 16.2-5 in regard to the Investigation of Complaint IN00434278.
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 0
Date: Apr 1, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00430164.
Complaint Details
Complaint IN00430164 was investigated and found to have no related deficiencies; the complaint was not substantiated.
Findings
No deficiencies related to the allegations in Complaint IN00430164 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint.
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 0
Date: Jan 25, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00423088.
Complaint Details
Complaint IN00423088 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Inspection Report
Original Licensing
Census: 82
Deficiencies: 1
Date: Oct 19, 2023
Visit Reason
This visit was for a State Residential Licensure Survey conducted on October 19, 2023, to assess compliance with state regulations.
Findings
The facility failed to follow the prescribed dose reduction for a resident's anticoagulant medication for 1 of 7 residents reviewed for pharmacy services, specifically Resident 8's Eliquis dose was not reduced as ordered until several months later.
Deficiencies (1)
Failed to follow the prescribed dose reduction for a resident's anticoagulant medication (Eliquis) for 1 of 7 residents reviewed for pharmacy services.
Report Facts
Residential Census: 82
Residents reviewed for pharmacy services: 7
Deficiency related resident count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stacey Gallardo | Executive Director | Signed the report |
| Director of Nursing | Interviewed regarding medication order compliance | |
| Administrator | Interviewed regarding medication order compliance and policy | |
| Director of Wellness | Responsible for auditing resident charts and implementing corrective actions | |
| Memory Care Director | Assists with auditing resident charts and corrective actions | |
| Nurse Practitioner | Interviewed regarding presence in facility and medication order |
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 0
Date: Sep 5, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00416192.
Complaint Details
Complaint IN00416192 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Inspection Report
Complaint Investigation
Census: 76
Deficiencies: 1
Date: Aug 15, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00411523, which was substantiated with state deficiencies related to misappropriation of resident medications.
Complaint Details
Complaint IN00411523 was substantiated. The facility failed to protect resident rights related to misappropriation of medications for 1 of 3 residents reviewed. The nurse involved resigned, and the resident's family, physician, and police were notified.
Findings
The facility failed to protect resident rights related to misappropriation of medications for one resident. The investigation revealed that a nurse removed controlled medications from the medication cart improperly, resulting in missing medication. The nurse resigned, and corrective actions including audits, staff education, and policy enforcement were implemented.
Deficiencies (1)
Facility failed to protect resident rights related to misappropriation of resident medications.
Report Facts
Residential Census: 76
Medication doses received: 90
Medication doses administered: 36
Medication doses available: 30
Medication count after administration: 53
Video duration: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stacey Gallardo | Executive Director | Signed report and involved in investigation |
| RN 2 | Nurse who removed medications improperly and resigned | |
| LPN 3 | Reported concerns about medication destruction and signing off | |
| PA 5 | Physician Assistant | Involved in medication order changes and alerted staff about medication removal |
| LPN 4 | Provided statement during investigation about medication handling |
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 0
Date: Jul 28, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00413404.
Complaint Details
Complaint IN00413404 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00413404 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Inspection Report
Complaint Investigation
Census: 76
Deficiencies: 0
Date: May 4, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00407032.
Complaint Details
Complaint IN00407032 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations are cited. Traditions of Columbus was found to be in compliance with 410 IAC 16.2-5 in regard to the Investigation of Complaint IN00407032.
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 0
Date: Mar 9, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00403502 and was conducted in conjunction with the Post Survey Revisit (PSR) to the PSR completed on December 21, 2022 related to Complaint IN00391651.
Complaint Details
Investigation of Complaint IN00403502 found no deficiencies related to the allegations. Complaint IN00391651 was corrected as of the prior PSR.
Findings
No deficiencies related to Complaint IN00403502 were cited, and Complaint IN00391651 was corrected. Traditions of Columbus was found to be in compliance with 410 IAC 16.2-5 regarding the investigation.
Report Facts
Residential Census: 63
Inspection Report
Follow-Up
Census: 63
Deficiencies: 0
Date: Mar 9, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the PSR completed on December 21, 2022, related to the Investigation of Complaint IN00391651 completed on February 3, 2023, and was also in conjunction with the Investigation of Complaint IN00403052.
Complaint Details
Complaint IN00391651 was corrected; Complaint IN00403052 had no deficiencies related to the allegations cited.
Findings
Complaint IN00391651 was corrected, and no deficiencies related to Complaint IN00403052 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the PSR.
Report Facts
Residential Census: 63
Inspection Report
Re-Inspection
Census: 66
Deficiencies: 1
Date: Feb 3, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to a Complaint Investigation completed on December 21, 2022, to verify correction of previously cited deficiencies related to resident safety and elopement risk.
Complaint Details
Complaint IN00391651 was not corrected as of the revisit date.
Findings
The facility failed to provide a safe environment for one resident reviewed for elopement, with documented incidents of the resident leaving the secured unit and facility. The facility had not implemented an effective systemic plan of correction to prevent recurrence of elopement incidents.
Deficiencies (1)
Failed to provide a safe environment for 1 of 3 residents reviewed for elopement.
Report Facts
Residential Census: 66
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stacey Gallardo | Executive Director | Signed the report and plan of correction. |
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 1
Date: Dec 20, 2022
Visit Reason
This visit was conducted for the investigation of complaints IN00397222 and IN00391651. Complaint IN00397222 was substantiated with no deficiencies cited, while complaint IN00391651 was substantiated with a state deficiency cited related to residents' rights.
Complaint Details
Complaint IN00397222 was substantiated with no deficiencies cited. Complaint IN00391651 was substantiated with a state deficiency cited at R0052 related to residents' rights violations including neglect and failure to prevent elopement.
Findings
The facility failed to provide a safe environment and prevent an elopement for one of three residents reviewed for neglect. Resident B exited the memory care unit through an alarmed door and was found outside the building. The facility had multiple documented incidents of Resident B exhibiting exit-seeking behavior and wandering. The facility implemented corrective actions including 1:1 supervision, updating care plans, staff inservices, monthly elopement drills, and ongoing screening for residents at risk of elopement.
Deficiencies (1)
Failed to provide a safe environment and prevent an elopement for Resident B, violating residents' rights to be free from neglect and involuntary seclusion.
Report Facts
Residential Census: 81
Survey Dates: 2022-12-20 to 2022-12-21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stacey Gallardo | Executive Director | Signed the report and involved in corrective action oversight |
Inspection Report
Renewal
Census: 56
Deficiencies: 3
Date: Jul 27, 2022
Visit Reason
This visit was for a State Residential Licensure Survey conducted on July 27, 2022, to assess compliance with state regulations.
Findings
The facility was found to have deficiencies in infection control practices, specifically related to insulin pen usage and improper mask wearing by staff during food service. The facility failed to follow proper infection control protocols including cleansing the insulin pen and resident's skin prior to insulin administration and ensuring staff wore masks correctly.
Deficiencies (3)
Failure to establish an infection control program that includes analyzing infectious symptoms, providing education on infection prevention, offering health information to residents, and reporting communicable diseases.
Failure to follow appropriate infection control practices related to insulin pen usage, including not cleansing the insulin pen top, not priming the pen, and not cleansing the resident's skin prior to insulin administration.
Staff wearing surgical masks improperly during food service and food preparation, including masks worn under the nose or chin.
Report Facts
Residential Census: 56
Infection Control Observations: 7
Audit Duration: 30
Audit Duration: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 6 | Licensed Practical Nurse | Named in infection control deficiency related to insulin pen usage |
| Director of Nursing | DON | Provided interview on proper insulin pen administration procedures |
| Director of Wellness | Initiated audit of insulin dependent residents | |
| Executive Director | Responsible for documentation and auditing mask usage | |
| Cook 2 | Observed wearing mask improperly during food preparation | |
| Cook 3 | Observed wearing mask improperly during food preparation | |
| Server 4 | Observed wearing mask improperly during food service | |
| Server 5 | Observed wearing mask improperly during food service | |
| Dietary Manager | Provided interview on mask wearing policy |
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