Commons at Orlando Lutheran Towers

In the surveyor’s words

From the most serious findings on record at Commons at Orlando Lutheran Towers, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Jun 4, 2026

  Based 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. […]

• Immediate jeopardy, isolatedF689Jun 4, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF755Mar 28, 2024

  Based 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. Findings: 1. Review of the medical record revealed resident #8 was admitted to the facility on [DATE] from the hospital. His diagnosis included schizoaffective disorder, bipolar, Alzheimer's disease, dementia, type II diabetes, and stage 4 kidney disease. […]

• No harm, potential for more than minimal, patternF756Mar 28, 2024

  Based 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). Findings: Resident #82, a [AGE] year-old female was admitted to the facility on [DATE], with her most recent readmission on 5/24/23. Her diagnoses included end stage renal disease, peripheral vascular disease, cardiomyopathy, hypertensive heart and chronic kidney disease with heart failure with stage 5 chronic kidney disease, chronic systolic (congestive) heart failure, venous thrombosis and embolism. […]

• No harm, potential for more than minimal, patternF694Apr 21, 2022

  Based 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). Findings: 1. Resident #59 was admitted to the facility on [DATE], and most recently readmitted on [DATE] from an acute care hospital. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set Five-day assessment with assessment reference date [DATE] revealed resident #59 had a Brief Interview for Mental Status score of 14 which indicated he was cognitively intact. Additionally, the assessment revealed the resident did not reject care from staff and received [CONDITION(S)]. […]