Commons at Orlando Lutheran Towers
210 Lake Avenue, Orlando, FL 32801 · Orange County · (407) 872-7088
168 certified beds, about 146 residents a day · Non profit - Corporation · Medicare and Medicaid since 1991
CMS abuse icon: cited for abuse in a recent inspection Part of a continuing care retirement community Certified for Medicaid Certified for Medicare
Overall
1 of 5
Health inspections
1 of 5
Staffing
4 of 5
Quality measures
4 of 5
CMS Care Compare ratings, data as of September 1, 2026 · CCN 105731 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on January 8, 2026, inspectors cited 1 health deficiency (the Florida average is 7.1, the national average 9.2).
Of 13 health citations since April 2022, 2 were rated as actual harm or immediate jeopardy to residents (2 immediate jeopardy).
CMS lists no fines against this home in the last three years.
Nurses and nurse aides worked 4.03 hours per resident per day, against 3.82 across Florida and 3.86 nationally. Registered nurses accounted for 0.81 of those hours.
41.7% of nursing staff left within the year CMS measured (Florida average 41.4%).
Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
404/22
503/24
108/24
101/26
206/26
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 13 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
2J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
8D
3E
0F
Potential for minimal harm
0A
0B
0C
June 4, 2026Complaint inspection · 2 citations
- J Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident's right to be free from neglect by not identifying an escalation in exit seeking behaviors; not implementing additional actions/interventions to prevent elopement; and not responding appropriately to an emergency exit door alarm to prevent elopement for 1 of 8 residents reviewed for elopement, of a total sample of 8 residents, (#1). These failures contributed to the elopement of resident #1 and placed her at risk of serious injury, impairment, or death. While outside the facility unsupervised, resident #1 fell and sustained a head injury and facial abrasion, leading to hospitalization. There was reasonable likelihood she could have become lost, harmed by strangers or hit by a motor vehicle. [...]
- J Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision to ensure vulnerable residents did not exit the facility without supervision for 1 of 8 residents reviewed for elopement, of a total sample of 8 residents, (#1). This failure contributed to the elopement of resident #1 and placed her at risk of serious injury, impairment, or death. While outside the facility unsupervised, resident #1 fell and sustained a head injury and facial abrasion. There was reasonable likelihood she could have become lost, been accosted/harmed by strangers or been hit by a motor vehicle while outside the facility unsupervised. On 5/19/26 at approximately 7:30 PM, the facility failed to prevent a resident with severe cognitive impairment from exiting the facility unsupervised. [...]
January 8, 2026Standard inspection · 1 citation
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services in accordance with professional standards of practice related to knee immobilizer application, the physician order, and failed to create a comprehensive care plan for 1 of 1 resident reviewed for limited range of motion, of a total sample of 43 residents, (#180).
August 29, 2024Complaint inspection · 1 citation
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview, and record review, the facility failed to follow professional standards of practice for blood glucose monitoring as ordered by the physician, for 1 of 3 residents reviewed for blood glucose monitoring, of a total sample of 6 residents, (#1).
March 28, 2024Standard inspection · 5 citations
- E Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services to assure accurate receiving and dispensing of a high-risk antipsychotic medication for 1 of 8 residents observed for medication administration, (#8) and failed to ensure medications were administered per physician's order prior to hemodialysis for 1 of 1 resident reviewed for dialysis, (#82), of a total sample of 48 residents.
- E Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on interview, and record review, the facility failed to ensure pharmacy recommendations were acted upon in a timely manner for 1 of 5 residents reviewed for unnecessary medications, of a total sample of 48 residents, (#82).
- D Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview, and record review, the facility failed to ensure Minimum Data Set (MDS) assessment was accurate for Functional Range Of Motion (ROM) for 1 of 2 residents reviewed for Limited ROM of a total sample of 48 residents, (#84).
- D Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent a medication administration error rate of 5% or greater for 1 out of 8 residents observed for medication administration, of a total sample of 48 residents, (#8). There were 3 medication errors in 25 opportunities for a medication error rate of 12%.
- D Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident was free of a significant medication error regarding administration of a discontinued high risk antipsychotic medication for 1 out of 8 residents observed for medication administration, of a total sample of 48 residents, (#8).
April 21, 2022Standard inspection · 4 citations
- E Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on observation, interview and record review, the facility failed to provide care and services for midline Intravenous (IV) catheters according to standards of practice and plan of care for 2 of 3 residents reviewed for IV catheters of a total sample of 46 residents, (#59 and #67).
- D Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment was transmitted within the required 7 day time frame for 1 of 1 resident reviewed for assessments of a total sample of 46 residents, (#2).
- D Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory therapy was administered as per physician orders for 1 of 3 residents reviewed for oxygen (O2) therapy of a total sample of 46 residents, (#29).
- D Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview and record review, the facility failed to prevent medication administration error rate of 5% or greater for 2 of 8 residents sampled for medication administration, (#279 and #84). There were 2 medication errors in 27 opportunities for a medication error rate of 7.41%.
Fire safety inspections
2 fire safety citations on file: 2 on March 28, 2024.
Every fire safety citation2 citations
- F Inspect, test, and maintain automatic sprinkler systems.
- F Install corridor and hallway doors that block smoke.
Fines and payment denials
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
Staffing
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Florida | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 4.03 | 3.82 | 3.86 |
| Registered nurses | 0.81 | 0.73 | 0.69 |
| All nursing staff on weekends | 3.72 | 3.49 | 3.42 |
| Nurse aides | 2.56 | ||
| Licensed practical nurses | 0.67 | ||
| Nursing staff turnover (share who left in a year) | 41.7% | 41.4% | 45.8% |
| Registered nurse turnover | 37.5% | 46.0% | 42.9% |
| Administrators who left | 0 |
CMS expects 3.58 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Staffing by quarter, from daily payroll records
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 4.15 on weekdays and 3.72 on weekends, 10% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.92 in April to June 2025 to 4.03 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 4.03 | 0.81 | 4.15 | 3.72 | 0.0% | 0 of 90 | 146 |
| Oct to Dec 2025 | 3.89 | 0.83 | 4.02 | 3.54 | 0.0% | 0 of 92 | 148 |
| Jul to Sep 2025 | 3.90 | 0.84 | 3.97 | 3.72 | 0.0% | 0 of 92 | 146 |
| Apr to Jun 2025 | 3.92 | 0.90 | 3.99 | 3.74 | 0.0% | 0 of 91 | 147 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Florida, Jan to Mar 2026 | 3.76 | 0.70 | 3.90 | 3.44 | 1.1% | 0.2% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Florida | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 22.0 | 8.7 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.3 | 0.3 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.0 | 0.7 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 3.9 | 2.5 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 0.9 | 1.5 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 22.2 | 9.5 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 2.1 | 4.5 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 4.4 | 8.6 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 25.6 | 26.1 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 8.8 | 9.1 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.7 | 2.1 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 0.9 | 1.1 | 1.8 |
Owners and operators
Legal business name: ORLANDO LUTHERAN TOWERS, INC.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Orlando Lutheran Towers, Inc | 5% or greater direct ownership interest | Organization | 100% | 05/01/1980 |
| Anello, Todd | Corporate director | Individual | 04/23/2021 | |
| Beumer, Denise | Corporate director | Individual | 08/03/2021 | |
| Bowles, Margret | Corporate director | Individual | 07/16/2021 | |
| Bunevich, Sue | Corporate director | Individual | 07/05/2022 | |
| Jennings, Jeffrey | Corporate director | Individual | 07/14/2020 | |
| Lee, Barbara | Corporate director | Individual | 06/26/2008 | |
| Maddron, Kevin | Corporate director | Individual | 11/02/2018 | |
| Pettit, Sarah | Corporate director | Individual | 05/09/2022 | |
| Steinberger, Martin | Corporate director | Individual | 03/20/2019 | |
| Tassell, Harold | Corporate director | Individual | 09/23/2024 | |
| Gerrity, Kerry | Corporate officer | Individual | 07/27/2010 | |
| Labrecque, Alicia | Corporate officer | Individual | 01/01/2009 | |
| Stawicki, Angela | Corporate officer | Individual | 08/14/2023 | |
| Henderson, Cathy | Operational/managerial control | Individual | 08/26/2013 | |
| Henderson, Cathy | Adp of the SNF | Individual | 03/12/2025 | |
| Lehman, Gary | Adp of the SNF | Individual | 03/12/2025 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Questions to ask on a visit
Chosen from this home's own inspection record.
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 5 problems in this area, most recently on June 4, 2026: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
- How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 5 problems in this area, most recently on March 28, 2024: "Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist."
- When is the care plan meeting, and can family attend it?Inspectors cited 2 problems in this area, most recently on March 28, 2024: "Ensure each resident receives an accurate assessment."
- How are allegations of abuse or neglect reported and investigated, and who tells the family?Inspectors cited 1 problem in this area, most recently on June 4, 2026: "Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody."
Other nursing homes nearby
- Westminster Towers Orlando, 0.6 mi · 3 of 5 stars · 22 citations
- Delaney Park Health and Rehabilitation Center Orlando, 0.8 mi · 3 of 5 stars · 21 citations
- South Orange Health and Rehabilitation Center Orlando, 1.3 mi · 5 of 5 stars · 15 citations
- Orlando Health and Rehabilitation Center Orlando, 2.2 mi · 1 of 5 stars · 66 citations
- Guardian Care Nursing & Rehabilitation Center Orlando, 2.5 mi · 2 of 5 stars · 18 citations
- Conway Lakes Health & Rehabilitation Center Orlando, 3.3 mi · 2 of 5 stars · 31 citations
- Westminster Baldwin Park Orlando, 3.4 mi · 5 of 5 stars · 8 citations
- Courtyards of Orlando Care Center and Rehab Orlando, 4 mi · 2 of 5 stars · 22 citations
Florida contacts for a concern about a nursing home
These are the official offices in Florida. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: Florida Agency for Health Care Administration, Long Term Care Services Unit, the state agency that inspects nursing homes for CMS and takes complaints about care.
- Resident advocate: Florida Long-Term Care Ombudsman Program, 1-888-831-0404. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
- State inspection reports: FloridaHealthFinder, where Florida publishes its own records on licensed homes.
Common questions
- What is Commons at Orlando Lutheran Towers's Medicare star rating?
- CMS rates Commons at Orlando Lutheran Towers 1 out of 5 stars overall, with 1 for health inspections, 4 for staffing and 4 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Commons at Orlando Lutheran Towers get at its last inspection?
- 1 health deficiency at the standard inspection on January 8, 2026. The Florida average is 7.1.
- Has Commons at Orlando Lutheran Towers been fined?
- CMS lists no fines in the last three years.
- Does Commons at Orlando Lutheran Towers accept Medicaid?
- It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
- Who owns Commons at Orlando Lutheran Towers?
- CMS lists 17 owners and managers. Legal business name: ORLANDO LUTHERAN TOWERS, INC.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.