Lyonsview Health and Rehabilitation Center
On Medicare Special Focus status, a serious quality warning. Visit in person and ask tough questions before deciding.
based on 73 Google reviews

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Quality Concerns Identified
Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.
- Special Focus Facility (under heightened CMS scrutiny)
- Abuse citation on record
- Low overall rating (1/5 stars)
- Low staffing rating (1/5 stars)
- Above-median deficiencies (11 vs median 5.0)
- High staff turnover (60%)
- High RN turnover (63%)
Bottom 25% in TN · Critically understaffed (RN) · Worst in CHAMPION CARE chain · $99,788 in fines · Special Focus Facility (CMS) · Abuse citation
What this means for your family
While the facility offers strong rehabilitation therapy and engaging activities, the inconsistency in care quality is a significant risk. If you choose this facility, we strongly recommend daily, unannounced visits to ensure your loved one's hygiene and medical needs are being met, as multiple families have reported neglect and slow response times.
Google Reviews
Google Reviews
73 reviews on Google“Lyonsview Health and Rehabilitation Center (formerly Brakebill) receives highly polarized feedback, with some families praising the dedicated nursing and therapy staff, while others report severe neglect and hygiene issues. While recent renovations and specific staff members are frequently highlighted as strengths, recurring complaints regarding understaffing, slow response times to call buttons, and poor communication suggest significant inconsistency in care quality.”
Quality Themes
Tap a score for detailsStrengths
- Dedicated and compassionate nursing staff
- Effective physical and occupational therapy teams
- Clean, recently renovated facility areas
- Active and engaging activities department
Concerns
- Chronic understaffing leading to slow call button response times (mentioned by 5 reviewers)
- Poor hygiene and failure to assist with incontinence care (mentioned by 4 reviewers)
- Inconsistent communication between departments and with families (mentioned by 3 reviewers)
- Inadequate meal service (cold food or missing meals) (mentioned by 3 reviewers)
Rating Trends
Tap a year to see what changed
Distribution · 76 analyzed
How They Respond to Reviews
This facility responds to some reviews.
Questions for Your Tour
- 1I noticed some great feedback about your activities department; what are some of the most popular daily programs for residents here?
- 2With the recent renovations to the facility, how have the updated common areas improved the dining experience for residents?
- 3How does the nursing team ensure that medication management is handled accurately and consistently throughout every shift?
- 4What specific protocols are in place to ensure that call buttons are answered promptly, especially during busy meal times or night shifts?
- 5How does the staff coordinate communication with families to ensure we are always updated on any changes in our loved one's care?
- 6In the event of a medical emergency after hours, what is the process for contacting physicians and notifying the family?
Personalized based on this facility's data
Key Review Excerpts
“My 97 year old mother entered Westmoreland rehab suffering with a severe infection and I was doubtful if she could return to her previous self-sufficient life. After a two week stay she has amazingly returned to her prior life possibly even better than before.”
“Had 2 patient meetings with the care team during the entire time. Lost one denture and one hearing aid. Had dimentia patients freely roaming and coming in his room at all times, taking his snacks and soft drinks, standing over his bed staring at him.”
“The employees are rude and lazy, and a few behaved as if they were on something. There was human feces all over the toilet and walls and floor. Oh and the wand that hangs behind the toilet that I guess they use to hose the patients down with was also covered in feces.”
Staffing
Staffing Hours
per resident/day · Medicare 2026Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.
Quality Measures
Quality Measures
Resident outcomes compared with national, state, and local averages · 17 measures
6
measures
8
measures
3
measures
Residents vaccinated for pneumonia
Residents whose walking got worse
Residents vaccinated for the flu
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Residents needing more daily help over time
Residents on anti-anxiety or sleep medication
Short-stay residents vaccinated for pneumonia
Short-stay residents vaccinated for the flu
Short-stay residents newly given antipsychotics
US average from Medicare published data
Inspection History
Medicare Inspection History
3-year lookback · Medicare 2026
This facility has recurring issues with protecting residents from abuse and neglect, with families filing complaints that led to 6 deficiency citations across multiple surveys. The most frequent problems involve resident protection, food safety and pest control, and fire safety systems. While the facility corrects deficiencies when cited, the pattern of repeated violations in critical areas like abuse prevention suggests ongoing operational challenges that families should carefully evaluate.
Jul 24, 2024Complaint2
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Apr 13, 2023Routine8
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Administration Deficiencies
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Administration Deficiencies
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Environmental Deficiencies
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Nursing and Physician Services Deficiencies
Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Quality of Life and Care Deficiencies
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Quality of Life and Care Deficiencies
Provide activities to meet all resident's needs.
Apr 13, 2023Complaint4
Nursing and Physician Services Deficiencies
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Jun 30, 2021Routine1
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Aug 21, 2019Routine8
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Environmental Deficiencies
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure that testing and maintenance of electrical equipment is performed.
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Federal Penalties
Fine
Jul 24, 2024
$12,038
Ownership & Operations
Who Operates This Facility
Lyonsview Health and Rehabilitation Center
for profit
Chain Affiliation
Champion Care
21 facilities nationwide
Chain avg rating: 2.1/5 · Rank 16 of 20 (Worst)
Ownership & Management
Owners
Smoky Mountains Operations Holdings LLC
Owner · Organization
Ruvel, Menachem
Owner (parent company)
Weinberg, Yisroel
Owner (parent company)
Key personnel
Contact
Get in Touch
Contact this facility directly and verify the details that matter most to your family.
References & Resources
Medicare Care Compare
Official Medicare quality ratings, inspections & staffing data
Google Maps
Photos, directions & neighborhood info
Google Reviews
73 reviews from families & visitors
Official Website
Visit lyonsview-health.com
Medicare data downloads
Original nursing home datasets
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