Cycle 1
Health 2026-01-08 · Fire 2026-01-08
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Orlando, FL
Commons At Orlando Lutheran Towers
4-star overall rating with 4-star inspections with 1 recent health deficiencies
210 Lake Avenue, Orlando, FL
(407) 872-7088
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
168
Certified beds
Average residents
146
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1991-05-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.84
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.62
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.44
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.90
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.46
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.72
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.79
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.88
CMS adjusted RN staffing hours
Adjusted total hours
4.09
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
39%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,672
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
43.2
Composite VBP score used to determine payment impact.
Payment multiplier
0.9962
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.85
Baseline 19.21% · Performance 18.25% · Measure score 6.85 · Achievement 6.85 · Improvement 3.87
Healthcare-associated infections
1.24
Baseline 6.46% · Performance 7.46% · Measure score 1.24 · Achievement 1.24 · Improvement 0
Total nurse turnover
4.64
Baseline 57.14% · Performance 44.72% · Measure score 4.64 · Achievement 4.64 · Improvement 3.35
Adjusted total nurse staffing
4.55
Baseline 3.97 hours · Performance 4.37 hours · Measure score 4.55 · Achievement 4.55 · Improvement 1.74
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.93% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 412 · Observed rate 8.74% · Lower 95% interval 7.76% |
| Discharge to community | 61.88% |
50.57%
11.3 pts better
|
Better than the National Rate · Eligible stays 391 · Observed rate 57.03% · Lower 95% interval 55.93% |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 82.79% |
95.27%
12.5 pts worse
|
Numerator 178 · Denominator 215 |
| Falls with major injury | 1.4% |
0.77%
0.6 pts worse
|
Numerator 3 · Denominator 215 |
| Discharge self-care score | 35.5% |
53.69%
18.2 pts worse
|
Numerator 60 · Denominator 169 |
| Discharge mobility score | 26.04% |
50.94%
24.9 pts worse
|
Numerator 44 · Denominator 169 |
| Pressure ulcers or injuries, new or worsened | 3.26% |
2.29%
1 pts worse
|
Numerator 7 · Denominator 215 · Adjusted rate 2.37% |
| Healthcare-associated infections requiring hospitalization | 7.46% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 244 · Observed rate 6.56% · Lower 95% interval 5.17% |
| Staff COVID-19 vaccination coverage | 7.21% |
8.2%
1 pts worse
|
Numerator 15 · Denominator 208 |
| Staff flu vaccination coverage | 13.59% |
42%
28.4 pts worse
|
Numerator 28 · Denominator 206 |
| Discharge function score | 33.14% |
56.45%
23.3 pts worse
|
Numerator 56 · Denominator 169 |
| Transfer of health information to provider | 89.91% |
95.95%
6 pts worse
|
Numerator 98 · Denominator 109 |
| Transfer of health information to patient | 96.55% |
96.28%
0.3 pts better
|
Numerator 56 · Denominator 58 |
| Resident COVID-19 vaccinations up to date | 9.78% |
25.2%
15.4 pts worse
|
Numerator 9 · Denominator 92 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
2.1
0.1 pts better
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.0 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.2
0.4 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.8 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
97.8%
1.1 pts better
|
93.4%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.3% · Q2 99.1% · Q3 99.1% · Q4 100.0% · 4Q avg 98.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.3% |
99.2%
0.9 pts worse
|
95.5%
2.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.6% |
2.6%
2 pts worse
|
3.3%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 6.5% · Q3 4.6% · Q4 1.8% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.8% |
3.7%
2.9 pts better
|
11.4%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.1% · Q3 0.0% · Q4 1.1% · 4Q avg 0.8% |
| Percentage of long-stay residents who lose too much weight | 5.9% |
5.9%
About the same
|
5.4%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 4.0% · Q3 1.9% · Q4 3.3% · 4Q avg 5.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.5% |
15.7%
0.8 pts worse
|
19.6%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.6% · Q2 15.4% · Q3 18.5% · Q4 14.8% · 4Q avg 16.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.5% |
9.8%
5.3 pts better
|
16.7%
12.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 4.3% · Q3 3.1% · Q4 3.0% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 27.3% |
11.7%
15.6 pts worse
|
16.3%
11 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.6% · Q2 21.5% · Q3 29.1% · Q4 17.8% · 4Q avg 27.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.2% |
9.8%
12.4 pts worse
|
14.9%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.8% · Q2 21.6% · Q3 18.0% · Q4 19.0% · 4Q avg 22.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.4%
0.2 pts worse
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 0.7% · Q4 0.6% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.9% |
0.8%
0.1 pts worse
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 1.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.0% |
12.5%
7.5 pts worse
|
19.8%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.9% · Q2 23.8% · Q3 30.9% · Q4 15.3% · 4Q avg 20.0% |
| Percentage of long-stay residents with pressure ulcers | 3.5% |
5.1%
1.6 pts better
|
5.1%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 4.2% · Q3 4.3% · Q4 2.2% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.5% |
94.3%
2.8 pts worse
|
81.7%
9.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.1% · Q2 90.1% · Q3 92.2% · Q4 91.7% · 4Q avg 91.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.5% |
9.3%
3.8 pts better
|
12.0%
6.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.5% · Observed 5.4% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.5%
0.5 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 1.8% · Q4 1.2% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 86.1% |
94.7%
8.6 pts worse
|
79.7%
6.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 86.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.2% |
26.2%
2 pts better
|
23.9%
0.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.2% · Observed 22.3% · Expected 22.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-28 · Fire 2024-03-28
6 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-04-21 · Fire 2022-04-21
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-03-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-19
F · Potential for more than minimal harm
2024-03-28
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-04-19
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-02-05
D · Potential for more than minimal harm
2024-08-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-23
E · Potential for more than minimal harm
2024-03-28
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-04-23
E · Potential for more than minimal harm
2024-03-28
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-04-23
D · Potential for more than minimal harm
2024-03-28
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-04-23
D · Potential for more than minimal harm
2024-03-28
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-04-23
D · Potential for more than minimal harm
2024-03-28
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-04-23
E · Potential for more than minimal harm
2022-04-21
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2022-05-12
D · Potential for more than minimal harm
2022-04-21
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2022-05-12
D · Potential for more than minimal harm
2022-04-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-05-12
D · Potential for more than minimal harm
2022-04-21
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-05-12
Penalties and ownership
What sits behind the stars
Ownership
Orlando Lutheran Towers, Inc
5% Or Greater Direct Ownership Interest · Organization
Anello, Todd
Corporate Director · Individual
Beumer, Denise
Corporate Director · Individual
Bowles, Margret
Corporate Director · Individual
Bunevich, Sue
Corporate Director · Individual
Gerrity, Kerry
Corporate Officer · Individual
Henderson, Cathy
Operational/Managerial Control · Individual
Jennings, Jeffrey
Corporate Director · Individual
Labrecque, Alicia
Corporate Officer · Individual
Lee, Barbara
Corporate Director · Individual
Maddron, Kevin
Corporate Director · Individual
Pettit, Sarah
Corporate Director · Individual
Stawicki, Angela
Corporate Officer · Individual
Steinberger, Martin
Corporate Director · Individual
Tassell, Harold
Corporate Director · Individual
Nearby options
Other facilities in reach
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Westminster Towers
Orlando, FL
3-star overall rating with 2-star inspections with $22,133 in total fines with 7 recent health deficiencies
#2
Delaney Park Health And Rehabilitation Center
Orlando, FL
3-star overall rating with 2-star inspections with 12 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
South Orange Health And Rehabilitation Center
Orlando, FL
4-star overall rating with 4-star inspections with $14,442 in total fines with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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