Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Lyonsview Health And Rehabilitation Center during CMS and state inspections, most recent first.
A cognitively impaired resident with a history of wandering eloped from the facility by climbing out of a window, which was found open with the screen removed. The resident was discovered outside near a fence by a nurse who called for assistance. The resident was brought back inside with a small abrasion on their finger. The facility failed to provide adequate supervision and secure windows, leading to Immediate Jeopardy for the resident.
The facility failed to protect residents from physical abuse, involving incidents where a resident with cognitive impairment struck another, a resident with dementia squeezed and hit a roommate, and another resident entered a room and hit a fellow resident. Despite no injuries reported, these incidents were investigated, and police were notified.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision for a resident, leading to an elopement incident. The resident, who was cognitively impaired and had a history of wandering behaviors, was found outside the building near a fence. This incident occurred despite the resident being identified as a moderate risk for elopement in their assessment. The resident had expressed a desire to go home and was known to wander throughout the facility. On the night of the incident, the resident was last seen at the nurse's station before returning to their room. The resident's room door was closed, and the window was found open with the screen removed, indicating the resident had climbed out. A nurse discovered the resident outside and called for assistance to bring the resident back inside. The resident was appropriately dressed and had a small abrasion on their finger but no other injuries. The facility's policy on elopement response was not effectively implemented, as staff did not prevent the resident from leaving through the window. The incident resulted in Immediate Jeopardy for the resident and placed other residents at risk. The facility's failure to secure windows and provide adequate supervision contributed to the deficiency.
Removal Plan
- The facility held a Quality Assurance Performance Improvement meeting to ensure building windows were all secure, review the Elopement Response policy with staff, review the Abuse policy with staff, and review elopement protocol with staff.
- A head count was completed for all residents by the DON and designees and elopement assessments completed on all residents, and the elopement assessments were ongoing and were used to update elopement books with current pictures of those residents to be kept at each nurses' station.
- Physician's orders, care plans and TASK [CNA communication] were updated by MDS staff and included assessments completed by medical and psychiatric nurse practitioners for Resident #1.
- All windows were checked and secured per regulations by the Maintenance Director and the Facility Manager. Ongoing door checks were initiated by the Maintenance Director.
- Education was completed with current staff by the Administrator and DON and will be ongoing for new staff. Education included Abuse and Elopement procedures and management. Continuing education was provided via telephone to include staff not available to attend in person.
- Elopement drills were completed and will be ongoing.
- Elopement education is ongoing through monthly staff meetings, orientation, and in-services for employees.
- Ongoing window audits were initiated by the Environmental Service Director to ensure secure windows for all residents.
- Monitoring will be completed by a designated monitor who performs daily rounds to check for window security.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by incidents involving three residents. Resident #2, who was cognitively intact, was involved in an altercation with Resident #3, who had severe cognitive impairment. Resident #3, unable to complete a mental status interview, struck Resident #2 in the face. Despite Resident #2's claim that the contact was a mere tap and caused no injury, the incident was reported to the police, and a facility investigation was conducted. The psychiatric evaluation of Resident #3 indicated confusion and a lack of mental capacity to recall the incident. Another incident involved Resident #4, who was cognitively intact, and Resident #5, who had a history of vascular dementia. Resident #5 was observed squeezing and hitting Resident #4, leading to their immediate separation and Resident #5's transfer to a hospital for evaluation. Despite the physical contact, Resident #4 reported no injuries or discomfort. The police were notified, but no official report was filed. The psychiatric evaluation of Resident #5 noted increased behavioral issues, prompting further psychiatric assessment. A third incident occurred between Resident #6, who was cognitively intact, and Resident #7, who had severe cognitive impairment. Resident #7 entered Resident #6's room and hit her on the arm. Although Resident #6 described the contact as a light tap and expressed no fear or threat, the police were notified. A psychiatric evaluation of Resident #7 revealed confusion and no recollection of the incident. The facility's administrator confirmed the occurrences of these incidents, acknowledging the physical contact between the residents.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 108 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Knoxville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| West Hills Health And Rehab | 2.4 mi | ★★★★★ | 0 | 0 |
| Legacy Park Health And Rehabilitation | 2.9 mi | ★★★★★ | 7 | 0 |
| Wellpark Health And Rehabilitation | 3 mi | ★★★★★ | 2 | 0 |
| Nhc Healthcare, Ft Sanders | 3.6 mi | ★★★★★ | 7 | 0 |
| Fort Sanders Tcu | 3.8 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.