Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 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.
Unsanitary fixed kitchen cooking equipment was observed in the kitchen, including a convection oven, tilt skillet, and front oven with dried, dark brown food debris on multiple surfaces. The DM confirmed the equipment was unclean and in an unsanitary condition, and the facility policy required all food-handling equipment to be cleaned and sanitized.
Dining Room Not Open on Weekends: The facility did not keep the main dining room open for resident use on weekends, instead using in-room only dining. Several residents said they wanted the option to eat in the dining room with others on the weekends, while CNA staff confirmed the dining room was not open and residents were redirected when they asked about it. The DON/Administrator confirmed weekend dining room access was not available.
A resident with heart disease, DM2, and an old MI had a quarterly MDS completed 49 days late. The RN MDS Coordinator confirmed quarterly MDS assessments were to be completed within 14 calendar days of the ARD and that the resident’s assessment was completed late.
Missing dialysis communication and return assessment documentation: The facility failed to maintain communication with the dialysis center and failed to document the resident’s status after dialysis for a resident with ESRD, Parkinson’s disease, diabetes, and severe cognitive impairment. Dialysis communication forms were incomplete on multiple treatment days, with missing pre/post weights, treatment times, fluid removal, intake, catheter status, condition changes, and vital signs. An LPN said she entered vital signs in the EMR instead of the dialysis form, and the DON confirmed the missing information was not documented in the form or EMR.
The facility failed to ensure the Dietary Manager met the job description requirement for accredited dietetic training and certification. Review of the employee file showed no certificate of completion, and the DM stated he was still working on dietary certification. HR confirmed the DM had not completed the required accredited course work.
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.
Unsanitary Fixed Kitchen Cooking Equipment
Penalty
Summary
The facility failed to maintain sanitary kitchen equipment in 1 of 1 kitchen observed. Review of the facility policy titled, Food Safety Requirements, dated 3/26/2025, stated that all equipment used in handling food shall be cleaned and sanitized and handled in a manner to prevent contamination, and that staff shall follow facility procedures for cleaning fixed cooking equipment. During an observation on 5/17/2026 at 10:40 AM with the Dietary Manager, a line of fixed kitchen cooking equipment, including a convection oven, tilt skillet, and front oven, was observed in unclean and unsanitary conditions with dried, dark brown food debris on multiple surface areas of each unit, including the front and sides. During an interview on 5/17/2026 at 10:48 AM, the Dietary Manager confirmed the debris was present on the convection oven, tilt skillet, and front oven and stated each piece needed a cleaning and was in an unsanitary condition.
Dining Room Not Open on Weekends
Penalty
Summary
The facility failed to ensure the main dining room was open for resident use on 2 of 7 days of the week, affecting resident access to communal dining and self-determination. Review of the facility’s Resident Rights policy stated that all residents will be treated equally and have the right to a dignified existence, self-determination, and communication with access to persons and services inside and outside the facility. During the initial tour, the activity calendar showed in-room only dining for the weekends, and the Administrator confirmed the dining room was not open on the weekends for dining. Several residents stated they wanted the option to eat in the dining room on weekends. One resident said they would like to eat there with everyone else on the weekends and that some people want to bring their families and see everybody. Another resident stated they would like the option to eat in the dining room on weekends if they felt like it, even if not every weekend. A third resident said they would prefer to eat in the dining room on the weekends. CNA staff stated the dining room was not open on weekends and that residents were redirected when they did not understand the restriction. The Administrator stated the facility had gone to in-room dining during the last COVID outbreak and residents appeared to have had low turnout after the outbreak for meal service in the main dining room.
Late Quarterly MDS Assessment
Penalty
Summary
The facility failed to complete quarterly MDS assessments within the required regulatory time frames for 1 resident out of 33 reviewed. Review of the MDS 3.0 RAI Manual showed that quarterly assessments must be completed at least every 92 days following the previous OBRA assessment, and the MDS completion date must be no later than 14 days after the ARD. Resident #20 was admitted with diagnoses including heart disease, diabetes mellitus type 2, and old myocardial infarction. The resident’s quarterly MDS assessment was completed on 5/18/2026 and was 49 days past due. During interview, the RN MDS Coordinator stated quarterly MDS assessments were to be completed within 14 calendar days of the ARD and confirmed that Resident #20’s quarterly assessment was completed late.
Missing dialysis communication and return assessment documentation
Penalty
Summary
The facility failed to maintain ongoing communication and collaboration with the dialysis facility and failed to document the resident’s status upon return from dialysis for Resident #113, who was admitted with Parkinson’s disease, end stage renal disease with dialysis, and diabetes. The quarterly MDS showed the resident had a BIMS score of 4, indicating severe cognitive impairment. The facility policy required ongoing assessment before and after dialysis, communication with the dialysis facility, and documentation of the resident’s access site status upon return from treatment. Review of the dialysis communication sheets for April and May 2026 showed missing documentation for dialysis pre-weight, post-weight, start and end times, fluid removed, meal/snack intake, catheter status and location, changes in condition, and vital signs on multiple treatment dates. Post-dialysis information, including catheter location status, catheter dressing, bleeding, general condition, and vital signs, was also not recorded on multiple dates. An LPN stated she documented vital signs in the EMR rather than on the dialysis communication sheets, and the DON confirmed the nurse was to obtain missing information from the dialysis facility and document it on the dialysis communication form and in the EMR. The DON also confirmed the forms were not completed in entirety and the required information was not documented in the EMR. The LPN later confirmed she called the dialysis center for missing information but did not document the information received on the form or in the EMR.
Dietary Manager Lacked Required Dietetic Training
Penalty
Summary
The facility failed to ensure the Dietary Manager completed accredited course work in dietetic training and certification, despite the job description requiring a high school diploma and graduation from an accredited course in dietetic training approved by the American Dietetic Association. Review of the Dietary Manager’s employee file showed no certificate of completion or other documentation that would satisfy the job description requirement. The Dietary Manager had been in the role since 3/13/2018 and stated during interview that he was still working on dietary certification when asked whether he had completed the required accredited course work. Human Resources later confirmed that the Dietary Manager had not completed an accredited course in dietetic training and certification.
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.
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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 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 | ★★★★★ | 0 | 0 |
| Wellpark Health And Rehabilitation | 3 mi | ★★★★★ | 7 | 0 |
| Nhc Healthcare, Ft Sanders | 3.6 mi | ★★★★★ | 7 | 0 |
| Fort Sanders Tcu | 3.8 mi | ★★★★★ | 1 | 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 August 2026) and official state health department websites.