Knox County

Lyonsview Health and Rehabilitation Center

Special Focus Facility candidate
Medicare rating
1 out of 5
5
findings of immediate jeopardy, the most serious kind
30%
less nursing care than its residents are expected to need, against a research benchmark
$12,038
in federal fines recorded since 2024

Medicare’s overall rating for this home. The inspection part of it is graded on a curve against other Tennessee homes, so a star here does not mean what it means in another state.

5837 Lyons View Pike, Knoxville, TN 37919 · (865) 584-3902
222 beds · about 165 residents on a typical day · for-profit limited liability company

Staffing

All nursing staff, per resident, per day
3 hours 33 minutes

Residents here are expected to need about 5 hours 3 minutes, given how sick they are. This home reports 30% less. The average Tennessee home reports 3 hours 48 minutes.

Registered nurses only
13 minutes

Registered nurses have the most training of the nursing staff on a shift. Residents here are expected to need about 1 hour 14 minutes of their time. This home reports 83% less.

Nursing staff who left in the past year
59%

About half of the nursing staff left within a year. High turnover means the people caring for your family member keep changing. The average Tennessee home reports 49%.

Where the benchmark comes from

Staffing is the measure most closely linked to how residents do, and the one families almost never see. How much nursing care a resident needs depends on how sick they are, so we compare this home against the level its own residents are expected to need. The marker on the first two bars shows that level. It is a research benchmark, not a legal limit. The hours shown are the hours the home filed with Medicare, before any adjustment for how sick its residents are.

What inspectors found

Inspectors visit every nursing home and write up what they find. This home has 19 findings on record going back to 2021, 2 of them after someone filed a complaint. Of the 19, 7 are from the last three years.

The 8 serious findings here

Immediate jeopardy July 24, 2024 From a complaint

Accidents and supervision

The home did not keep the building free of hazards, or did not supervise a resident closely enough to prevent an accident.

The home had already fixed this before inspectors arrived.

Medicare’s wording

Federal tag F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Actual harm April 13, 2023

Quality of care

A resident did not get treatment and care that followed their orders, their own preferences and their goals.

The home fixed this on May 26, 2023.

Medicare’s wording

Federal tag F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Actual harm April 13, 2023

No doctor for the resident

The home took in a resident without a doctor’s written approval, or did not keep them under a doctor’s care.

The home fixed this on May 26, 2023.

Medicare’s wording

Federal tag F710Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.

Immediate jeopardy April 13, 2023

Food safety

Food was not stored, prepared, or served safely.

The home fixed this on May 26, 2023.

Medicare’s wording

Federal tag F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Immediate jeopardy April 13, 2023

Poorly run

The home was not managed in a way that let it provide proper care.

The home fixed this on May 26, 2023.

Medicare’s wording

Federal tag F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Immediate jeopardy April 13, 2023

Leadership duties not met

The home did not have a governing body setting the rules for running it, or did not appoint a properly licensed administrator.

The home fixed this on May 26, 2023.

Medicare’s wording

Federal tag F837Establish 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.

Actual harm April 13, 2023

No proper plan of care

The home did not write or follow a full written plan for how a resident’s needs would be met.

The home fixed this on May 26, 2023.

Medicare’s wording

Federal tag F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Immediate jeopardy April 13, 2023

Pests not controlled

The home did not keep up a proper program to keep out mice, insects, and other pests.

The home fixed this on May 26, 2023.

Medicare’s wording

Federal tag F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Everything on record

Immediate jeopardy 5 Has caused, or was likely to cause, serious injury, harm, impairment or death
Actual harm 3 A resident was hurt
Potential for harm 11 Could have caused harm. No one was hurt. The most common kind.

293 of the 303 nursing homes in Tennessee have fewer findings of harm or immediate jeopardy on record than this one.

What these levels mean

Immediate jeopardy The most serious finding there is. Medicare’s words: noncompliance that has caused, or is likely to cause, serious injury, harm, impairment, or death. About 2 in every 100 findings nationally.

Actual harm A resident was really hurt, not just put at risk. About 3 in every 100 findings.

The letter is Medicare’s own code for how many residents were involved. Immediate jeopardy covers J, K and L. Actual harm covers G, H and I. The later the letter, the more residents were affected.

The plain-English line under each finding describes the rule the inspector cited. It is not an account of what happened. Medicare’s own wording of the rule is printed with it, and the full inspection report is the record of the incident.

This home has 3 findings under three federal tags that are counted together, and they do not all mean abuse: F600 is abuse or neglect, F602 is the wrongful use of a resident’s belongings or money, and F603 is involuntary seclusion. Medicare also publishes a separate abuse warning icon, which is narrower and time-limited, and this home does not currently carry it.

What you can do

Numbers only go so far. These are two things most families do not know they can do.

Ask for today’s staffing sheet

Every nursing home must post how many nurses are working each shift, keep 18 months of it, and show it to you on request. Ask for today’s, then last Saturday’s. Weekends are when staffing thins out.

Call the ombudsman before you decide

Every state has a free, confidential long-term care ombudsman. You can ask how many complaints a specific home has had and what they were about. You can find your state’s office through its department of aging.

Where this comes from

Inspection findings, staffing hours, fines and star ratings on this page are published by the Centers for Medicare & Medicaid Services, a federal agency, and are current as of August 1, 2026. We reload after each monthly release, and the footer of every page shows both the release date and the date we loaded it. The federal ID for this home is 445114.

What these numbers do not say

Fines can be appealed and reduced. The amount shown is what CMS had recorded as of this release. Medicare’s penalties file covers a rolling window of the last few years rather than a home’s whole history, so this is what Medicare publishes today and not everything this home has ever been fined. The year beside the figure above is the earliest fine Medicare still lists for it.

The level of care residents here are expected to need, and the gap, are not Medicare figures. We work them out from this home’s own Medicare case-mix score using the published CASE formula (Harrington and others, Journal of the American Geriatrics Society, 2025). It is a research benchmark, not a legal limit.

Inspection findings are recorded by state inspectors on behalf of Medicare. Staffing hours come from payroll records the home files with Medicare, and Medicare audits a sample of them. Star ratings partly reflect quality measures the home reports about itself, which is why we show inspections and staffing separately rather than only the star.