Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Commons At Orlando Lutheran Towers during CMS and state inspections, most recent first.
A resident with dementia and severely impaired decision-making repeatedly paced the unit, pushed on exit doors, and triggered the emergency door alarm, but staff did not escalate supervision or respond appropriately when the alarm sounded. Video showed the resident leaving through an exit door and descending the stairs, while security later reset the alarm without checking the area. The resident was not accounted for for about two hours and was later found to have fallen outside, sustaining a head injury and facial abrasion that led to hospitalization.
A resident with severe cognitive impairment and known exit-seeking behavior was not adequately supervised after staff observed repeated wandering and attempts to push through emergency exit doors. Although the resident had a wander-alert bracelet and staff redirected her at times, she was able to leave the unit, descend a stairwell, and exit the building without staff knowledge. She was later found outside by a bystander and taken to the ER with a head injury and facial abrasion.
A resident with Alzheimer’s dementia, limited ROM, and a history of hip and knee fractures was observed with a left knee immobilizer and a folded pillowcase stuffed inside it. The EMR had no active physician order for the immobilizer, and the care plan had no related interventions. Staff, including a CNA, LPNs, PTA, DOR, and DON, acknowledged the device was being used without a documented order and that the pillowcase remained in place because of resident discomfort.
A facility failed to follow professional standards for blood glucose monitoring for a resident with type 2 diabetes. Despite physician orders for regular accu-checks, there were 12 instances of missing documentation over a week. The DON confirmed the lack of documentation and stated that nurses were expected to follow orders and document results.
Failure to Prevent Resident Elopement After Escalating Exit-Seeking Behavior
Penalty
Summary
The facility failed to protect a resident from neglect by not identifying an escalation in exit-seeking behavior, not implementing additional interventions to prevent elopement, and not responding appropriately to an emergency exit door alarm. The resident had vascular dementia, hemiplegia and hemiparesis, aphasia, cardiac arrest, congestive heart failure, and atypical atrial flutter. The MDS showed short-term and long-term memory problems and severely impaired cognitive skills for daily decision-making. The resident was identified as at risk for elopement, and an electronic wander-alert bracelet had been applied after staff documented restlessness, pacing, statements about wanting to go home, and pushing on exit doors. On the evening of the incident, multiple staff members observed the resident pacing the unit, going to the emergency exit doors, and setting off the alarm more than once. Staff redirected the resident back to the dayroom or other areas, but the resident continued to exhibit exit-seeking behavior. One CNA stated the resident was seen in the hallway shortly before she was later found missing, and an LPN stated the resident was still walking the unit and pushing doors after she had redirected her earlier in the shift. An RN also confirmed the resident repeatedly went to the emergency exit door and triggered the alarm multiple times, but could not explain why closer supervision or other interventions were not used despite the repeated behaviors. Video footage showed the resident descending the staircase from the second floor, attempting to open a locked door into the first-floor unit, then turning toward the exit door and leaving the facility. About five minutes later, security personnel turned off the exit door alarm, and the video did not show them checking outside or around the door area. The facility was unaware of the resident's whereabouts for approximately two hours until staff learned she had been transported to the hospital emergency department. The resident was later reported to have fallen outside the facility and sustained a head injury and facial abrasion, leading to hospitalization.
Failure to Supervise Resident with Exit-Seeking Behavior
Penalty
Summary
The facility failed to provide adequate supervision to prevent a vulnerable resident with severe cognitive impairment from exiting the facility unsupervised. The resident had diagnoses including vascular dementia, hemiplegia and hemiparesis, aphasia, cardiac arrest, congestive heart failure, and atypical atrial flutter. Her MDS showed short-term and long-term memory problems and severely impaired cognitive skills for daily decision-making. The record also showed she was identified as at risk for wandering/elopement and had an electronic wander-alert bracelet applied, with a physician order for the bracelet because she had displayed and/or voiced exit-seeking behavior. On the evening of the incident, multiple staff observed the resident pacing, wandering the unit, and going to emergency exit doors. Staff reported that she repeatedly pushed on exit doors and set off alarms several times. One CNA recalled redirecting her from the emergency exit door earlier in the shift, and an RN stated the resident went to the emergency exit door several times and was last seen in the dayroom. The ADON also reported the resident was active, walking around common areas, the dining room, and hallways. Despite these observations and the resident’s repeated exit-seeking behavior, the resident was not kept under sufficient supervision to prevent her from leaving the unit and facility without staff knowledge. Video review showed the resident descending the stairwell from the second floor, reaching the first-floor landing, attempting to enter a secured door, then turning back and exiting through the outside door at approximately 7:30 PM. The facility did not know her whereabouts until later that evening when staff learned she had been transported to the hospital emergency room. Hospital records and family report indicated she was found on the ground by a bystander and had sustained a head injury and facial abrasion. The report also states that while outside the facility unsupervised, she was exposed to environmental hazards including motor vehicles, stairs, uneven surfaces, gravel, and cobblestone roads.
Unordered Knee Immobilizer Use and Missing Care Plan
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice for a resident with Alzheimer’s dementia, osteoporosis, a history of falls, hip and left knee fractures, and status post left total knee arthroplasty. The resident’s MDS showed severely impaired memory, limited range of motion to the arms and left leg, wheelchair use, and dependence on staff for toileting, personal hygiene, lower body dressing, and mobility. During observation, the resident was sitting in her wheelchair with a left knee immobilizer in place and a folded pillowcase stuffed under the immobilizer, and she was unable to explain why she had the immobilizer or the pillowcase. Review of the medical record found no active physician order for the left knee immobilizer and no care plan interventions related to the immobilizer or the pillowcase. Staff interviews showed the CNA who showered the resident was unsure how often the immobilizer should be applied or removed and did not know why the pillowcase was there, while an LPN confirmed there was no physician order but believed there should be one. Another LPN and the PTA also acknowledged the immobilizer was being used without an order, and the PTA stated he left the pillowcase in place because the resident had complained of discomfort. The DOR stated therapists reviewed hospital records and generated an order in their system, but the DON confirmed there was no physician order in the EMR and that an order should first be obtained for use of a device such as an immobilizer.
Failure to Document Blood Glucose Monitoring
Penalty
Summary
The facility failed to adhere to professional standards of practice for blood glucose monitoring as ordered by the physician for one resident. The resident, who was admitted from an acute care hospital, had multiple diagnoses including type 2 diabetes mellitus. The care plan for diabetes management included administering medication as ordered and monitoring blood glucose levels before meals, at bedtime, and as needed. The physician's order specified that nurses should perform accu-checks and report any results below 70 or above 300. However, a review of the Medication Administration Record (MAR) for June 2024 revealed that there were 12 instances of missing documentation for the required accu-checks between the dates of June 5 and June 12, 2024. The Director of Nursing confirmed the absence of documentation and stated that the expectation was for nurses to follow physician orders and document the results. No additional evidence was provided to show that the accu-checks were performed as ordered.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Orlando
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westminster Towers | 0.6 mi | ★★★★★ | 0 | 0 |
| Delaney Park Health And Rehabilitation Center | 0.8 mi | ★★★★★ | 0 | 0 |
| South Orange Health And Rehabilitation Center | 1.3 mi | ★★★★★ | 0 | 0 |
| Orlando Health And Rehabilitation Center | 2.2 mi | ★★★★★ | 3 | 0 |
| Guardian Care Nursing & Rehabilitation Center | 2.5 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.