Commons at Orlando Lutheran Towers
210 Lake Avenue, Orlando, FL 32801 · Orange County · 168 certified beds · avg 146 residents/day · certified since May 1, 1991
Abuse citation flag (CMS)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Jun 4, 2026 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jul 16, 2026 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Jun 4, 2026 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jul 16, 2026 (Deficient, Provider has date of correction)
All citations in the current public record (13)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jun 4, 2026 | ▲ J · Immediate jeopardy, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Jun 4, 2026 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jan 8, 2026 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Aug 29, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Mar 28, 2024 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Mar 28, 2024 | E · Potential for harm, repeated | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Mar 28, 2024 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Mar 28, 2024 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Mar 28, 2024 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| Apr 21, 2022 | E · Potential for harm, repeated | The facility did not safely and appropriately administer IV fluids (fluids given through a vein) for residents who needed them. |
| Apr 21, 2022 | D · Potential for harm, one-off | The facility did not enter each resident's assessment information into the required format and send it to the state within 7 days of completing the assessment, as the rules require. |
| Apr 21, 2022 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Apr 21, 2022 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (5 → 1).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 4 | 0 | E |
| 2024 | 6 | 0 | E |
| 2026 | 3 | 2 | J ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
No fines or payment denials in the published 3-year window.
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Florida avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.32 | 4.03 | 3.95 | top 21% in Florida; top 28% in the U.S. |
| Registered Nurse hours | 0.86 | 0.76 | 0.69 | top 29% in Florida; top 23% in the U.S. |
| Weekend total nurse staffing | 3.99 | 3.68 | 3.50 | top 19% in Florida; top 23% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.73 | 0.53 | 0.48 | top 19% in Florida; top 14% in the U.S. |
| Total nursing staff turnover (%) | 41.7 | 41.4 | 45.8 | top 49% in Florida; top 41% in the U.S. |
| RN turnover (%) | 37.5 | 46.0 | 42.9 | top 33% in Florida; top 42% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.03, RN 0.81, weekend 3.72. Staffing rating: 4/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 5/5 · short-stay residents: 3/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Orlando Lutheran Towers, INC | Organization | 5% or Greater Direct Ownership Interest | 100% | 05/01/1980 |
| Anello, Todd | Individual | Corporate Director | NOT APPLICABLE | 04/23/2021 |
| Beumer, Denise | Individual | Corporate Director | NOT APPLICABLE | 08/03/2021 |
| Bowles, Margret | Individual | Corporate Director | NOT APPLICABLE | 07/16/2021 |
| Bunevich, Sue | Individual | Corporate Director | NOT APPLICABLE | 07/05/2022 |
| Gerrity, Kerry | Individual | Corporate Officer | NOT APPLICABLE | 07/27/2010 |
| Henderson, Cathy | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/26/2013 |
| Henderson, Cathy | Individual | ADP of the SNF | NOT APPLICABLE | 03/12/2025 |
| Jennings, Jeffrey | Individual | Corporate Director | NOT APPLICABLE | 07/14/2020 |
| Labrecque, Alicia | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2009 |
| Lee, Barbara | Individual | Corporate Director | NOT APPLICABLE | 06/26/2008 |
| Lehman, Gary | Individual | ADP of the SNF | NOT APPLICABLE | 03/12/2025 |
| Maddron, Kevin | Individual | Corporate Director | NOT APPLICABLE | 11/02/2018 |
| Pettit, Sarah | Individual | Corporate Director | NOT APPLICABLE | 05/09/2022 |
| Stawicki, Angela | Individual | Corporate Officer | NOT APPLICABLE | 08/14/2023 |
| Steinberger, Martin | Individual | Corporate Director | NOT APPLICABLE | 03/20/2019 |
| Tassell, Harold | Individual | Corporate Director | NOT APPLICABLE | 09/23/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
- "Does a pharmacist review every resident's medications and chart monthly, and how are their concerns acted on?"
- "Who completes resident assessments here, and how do you check them for accuracy?"
- "What is your current medication error rate, and what have you changed to bring errors down?"
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Westminster Towers | 0.6 mi | Orlando, FL | ★★★☆☆ | 2/5 | |
| Delaney Park Health and Rehabilitation Center | 0.8 mi | Orlando, FL | ★★★☆☆ | 2/5 | |
| South Orange Health and Rehabilitation Center | 1.3 mi | Orlando, FL | ★★★★★ | 4/5 | |
| Orlando Health and Rehabilitation Center | 2.2 mi | Orlando, FL | ★☆☆☆☆ | 1/5 | abuse |
| Guardian Care Nursing & Rehabilitation Center | 2.5 mi | Orlando, FL | ★★☆☆☆ | 2/5 | |
| Conway Lakes Health & Rehabilitation Center | 3.4 mi | Orlando, FL | ★★☆☆☆ | 2/5 | |
| Westminster Baldwin Park | 3.4 mi | Orlando, FL | ★★★★★ | 4/5 | |
| Courtyards of Orlando Care Center and Rehab | 4.0 mi | Orlando, FL | ★★☆☆☆ | 3/5 | |
| Westminster Winter Park | 4.0 mi | Winter Park, FL | ★★★★★ | 4/5 | |
| Alwyn C Cashe State Veterans Nursing Home | 4.1 mi | Orlando, FL | ★☆☆☆☆ | 2/5 | abuse |
| Avante at Orlando INC | 4.4 mi | Orlando, FL | ★★★☆☆ | 3/5 | |
| Solaris Healthcare College Park | 4.5 mi | Orlando, FL | ★★★☆☆ | 3/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 105731.