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Nursing HomeMedicaid Investigative

Lyonsview Health and Rehabilitation Center

On Medicare Special Focus status, a serious quality warning. Visit in person and ask tough questions before deciding.

5837 Lyons View Pike, Knoxville, TN 37919222 bedsLicensed & Active
1/5
Medicare
Inspection
Quality
Staffing
Google rating
3.6/5

based on 73 Google reviews

5
4
3
2
1
Lyonsview Health and Rehabilitation Center Nursing Home in Knoxville, TN — Street View
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10/ 10
critical Risk

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

Source: Medicare data

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 details
Food4.0Staff5.0Clean5.0Activities9.0Meds2.0Memory4.0Comms3.0ValueN/A

Strengths

  • 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

234'16(2)'18(3)'21(2)'23(21)'25(18)'26(10)

Distribution · 76 analyzed

5
45
4
5
3
2
2
1
1
23

How They Respond to Reviews

60%response rate

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.

Rehab patient's family · 2023★★★★★

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.

Long-term resident's family · 2023☆☆☆☆

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.

Caregiver for resident · 2023☆☆☆☆
Source: 73 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.22hrs
29%
Registered nurses for medical care
Total Nursing
3.57hrs
87%
All nurses + aides combined
Staff Turnover
56%
Lower is better (< 30% = good)
RN Turnover
77%
Lower is better (< 30% = good)

Both 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

Medicare Rating
1/ 5
Better Than Avg

6

measures

Worse Than Avg

8

measures

Mixed Results

3

measures

Long-Stay Residents
💉

Residents vaccinated for pneumonia

↑ Higher is better
This Facility15.4%
Worse than Avg
Here
15.4%
US
93.4%
TN
89.5%
Knox
95.7%
🚶

Residents whose walking got worse

↓ Lower is better
This Facility41.2%
Worse than Avg
Here
41.2%
US
15.3%
TN
18.5%
Knox
16.5%
💉

Residents vaccinated for the flu

↑ Higher is better
This Facility80.5%
Worse than Avg
Here
80.5%
US
95.5%
TN
94.5%
Knox
95.8%
😔

Residents with depression symptoms

↓ Lower is better
This Facility1.2%
Better than Avg
Here
1.2%
US
12.1%
TN
12.9%
Knox
14.2%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility26.0%
Worse than Avg
Here
26.0%
US
14.4%
TN
14.6%
Knox
13.3%
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility30.5%
Mixed vs Avgs
Here
30.5%
US
19.5%
TN
31.9%
Knox
24.9%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility25.3%
Worse than Avg
Here
25.3%
US
81.8%
TN
79.4%
Knox
88.8%
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility48.2%
Worse than Avg
Here
48.2%
US
79.7%
TN
79.8%
Knox
80.9%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility2.0%
Worse than Avg
Here
2.0%
US
1.6%
TN
1.6%
Knox
2.1%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

11deficiencies
1penalties
Well above state avg (5.9)
6 complaint-triggered
$99,788 in fines

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, 2024Complaint
2
0689Immediate jeopardy · IsolatedResolved (past non-compliance)

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0600Potential for harm · IsolatedCorrected

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, 2023Routine
8
0812Immediate jeopardy · WidespreadCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0835Immediate jeopardy · WidespreadCorrected

Administration Deficiencies

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

0837Immediate jeopardy · WidespreadCorrected

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.

0925Immediate jeopardy · WidespreadCorrected

Environmental Deficiencies

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

0841Potential for harm · WidespreadCorrected

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.

0372Potential for harm · PatternCorrected

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

0676Potential for harm · IsolatedCorrected

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.

0679Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Apr 13, 2023Complaint
4
0710Actual harm · IsolatedCorrected

Nursing and Physician Services Deficiencies

Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.

0656Actual harm · IsolatedCorrected

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.

0684Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

0600Potential for harm · IsolatedCorrected

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, 2021Routine
1
0600Potential for harm · IsolatedCorrected

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, 2019Routine
8
0812Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0925Potential for harm · WidespreadCorrected

Environmental Deficiencies

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

0921Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure that testing and maintenance of electrical equipment is performed.

0353Potential for harm · PatternCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0372Potential for harm · PatternCorrected

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

0609Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

0755Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

0321Potential for harm · IsolatedCorrected

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

Owner / Operator

Lyonsview Health and Rehabilitation Center

Organization Type

for profit

Chain Affiliation

Chain Name

Champion Care

Chain Size

21 facilities nationwide

Chain avg rating: 2.1/5 · Rank 16 of 20 (Worst)

Ownership & Management

Owners

Smoky Mountains Operations Holdings LLC

Owner · Organization

100%

Ruvel, Menachem

Owner (parent company)

39%

Weinberg, Yisroel

Owner (parent company)

39%

Key personnel

Smoky Mountains Realty LLC5% or Greater Mortgage InterestRuvel, MenachemOfficer / DirectorWeinberg, YisroelOfficer / DirectorHasemeier, EricManagerStiefel, BenjaminManager
Source: Medicare provider data

Contact

Get in Touch

Contact this facility directly and verify the details that matter most to your family.

References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

Safer Alternatives Nearby

Based on current clinical data, we identified 6 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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