Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 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 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.
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 July 2026) and official state health department websites.