Landmark Recovery was cited for three deficiencies regarding the murder at Praxis of Louisville by Landmark Recovery.
Here are the findings:
1. Failure to Conduct Required Patient Observations:
- Landmark Recovery’s Patient Observations Corporate Policy requires staff to conduct “Q Checks” at least every 30 minutes for the first four days of each treatment episode.
- A review of security footage confirmed that the Licensed Practical Nurse (LPN) and Patient Engagement Specialist (PES) on duty failed to conduct the required observations for Ms. Knight prior to and after the assault.
- The PES acknowledged entering Q30 observation entries into the medical record system without conducting the required visual checks of the patient, as mandated by the facility’s internal policy. This practice constitutes a violation of established observation and documentation protocols.
- Ms. Conrad, Ms. Hibbs, and Ms. Nelson were aware of this policy violation at the time of the site visit.
- Ms. Conrad stated that Mr. Ochs, the PES, was terminated as a result. However, Mr. Ochs contested this statement and said that he voluntarily resigned.
2. Failure to Enforce Restricted Access to Patient Living Quarters:
- Facility policy states that patients may not enter other patients’ living quarters.
- Security footage showed multiple instances of patients entering other rooms, including Ms. Hensley entering Ms. Knight’s room multiple times.
3. Failure to Provide Appropriate Medical Response for Withdrawal Management:
No clear documentation was found indicating that the prescriber had been notified of Ms. Hensley’s inability to receive her prescribed medication.
According to 908 KAR 1:372, Section 2, protocols must be developed and supported by a physician knowledgeable in addiction medicine to ensure appropriate care when a patient’s condition deteriorates.
A review of Ms. Hensley’s medical records confirmed she was prescribed Diazepam upon re-admission on 01/22/25, as she had previously been prescribed Diazepam at The Brook.
A treatment team note dated 01/29/25 stated, “Angela is currently prescribed a Diazepam taper but has not been able to receive this medication due to having a pharmacy lock from insurance.”
Medical records noted Ms. Hensley experienced withdrawal symptoms, including restlessness, runny nose, and anxiety, and continued to experience auditory hallucinations.
Not only does it sound like this death was preventable, but these are the same issues I have heard about at other facilities. It sounds like Landmark has a lawsuit on its hands. They were dinged for not performing patient checks and falsely stating that checks were completed. Ms. Henlsey wasn’t given her prescribed medication. Sounds like an insanity defense.
Here is how Landmark Recovery plans to correct the findings:
- Performing daily checks of surveillance cameras and requiring an administrator at each facility to visually check camera records to confirm that patient observations were completed.
- The immediate termination of staff members if they are found to be falsifying patient observations.
- Requiring patients to sign an additional consent form upon arrival to indicate they agree not to enter other patients’ rooms and termination from the treatment program for a second violation of the policy.
- Assigning staff to monitor residential hallways for loitering patients.
- Assigning an administrator to review camera footage weekly for patients who enter rooms inappropriately to ensure proper compliance and monitoring.
- Requiring the director of nursing to escalate details about the inability to receive patient medications, sending that information to the compliance department and attending provider (Landmark claimed Hensley did receive the medication she needed while in treatment.)
I am calling bullshit here. Time and time again, Landmark has refused to make the necessary changes. This has been a recurring issue since day one. I don’t see it getting any better. How many more people need to die inside a Landmark facility?
When WTHR reporter asked Matt Boyle for a statement after the findings, Matt lashed out. Matt texted back with, “Do you ever fucking stop? Seriously I hope you burn in hell.” Matt emailed the following statement: “As it relates to the confidential findings you somehow claim to have obtained regarding the sentinel event at our facility in Kentucky, I have attached evidence that our plan of correction was accepted by the state and our license remains in good standing. It is standard practice for regulatory bodies to review licensed facilities. Virtually all reviews reveal opportunities for performance improvement. Responding to opportunities with a plan of correction is a routine and important part of the quality improvement process in behavioral healthcare. I will further remind you that this particular facility operated for over eight years and served over 10,000 patients without a single sentinel event. I believe the state’s decision not to take action against our license reflects this reality.” Wow Matty, way to play the dicktim.
You can read the news story here.
I *really* hate to say it again, but this won’t change a thing at Landmark. It’s “business as usual” at Landmark. Same old, same old.
How many times have we seen massive deficiencies at Landmark? How many sites were shut down in Indiana? How many are currently massively not up to Landmark’s *own internal standards* yet are not shut down?
Landmark won’t get sued. If they do, daddy will settle out of court to avoid having to admit guilt.
Landmark issued a “plan of correction” – tell us, Matt, if the staff are required to go through such rigorous training, why are the same complaints at other facilities – just like we see in this article – happening?
Jessica Tate resigned. Real money says she got out because she finally was able to interpret the writing on the wall.
Molly Schaar – Jessica’s right hand – recently resigned.
Darien – their clinical trainer – resigned.
All three were corporate.
Now today 05/07/2025, news came to light that *another* Executive Director from a Louisville location resigned.
……and the Columbus, Ohio facility is YET AGAIN looking for a clinical director.
……..oh, and Matt keeps pushing up the starting wages for “directors” because the well is running dry.
No one who wants their reputation destroyed will work there, unless they have no other choice.
Sadly, because there’s no money/fraud going on, we won’t see a lawsuit, we won’t see Kentucky shut them down.
If Matt Boyle really did send that text – that should be making the rounds all over the news. If it’s a real text he sent, that proves he’s a spoiled little boy who wants everyone to like him.
Grow up, Matty. Look at how many have left your little sand castle. It’s just a bit more time before the tide comes and washes it all away.
I am hearing about issues at multiple facilities. The only facility I haven’t heard about is the new Colorado Springs facility. Since Landmark hasn’t been able to create a Google Business Profile (GBP) for that location, I can’t see any reviews. The reviews I do see for the other locations show that the facilities are a mess. I have had a few people reach with information, which I have not shared. I know nothing has changed after each assault, sexual assault, death, and any of the other issues reported. This is why I called bullshit on Landmark’s corrective plan and Matt’s email reply. Matt does what he wants to and this is proven over the years.
Matt did send that text. That’s the kicker!!! He lost his cool and exposed himself for the world to see. People get to see him lash out and be a jerk.
The new executive director of the Cleveland (Euclid) Ohio location is a convicted RECENT drunk driving felon.
This is the BEST Matt Boyle can do for directors is to hire convicted felons……and this very recent conviction was overlooked by HR and they hired this felon to run their program.
Read all about this felon here:
https://www.cleveland19.com/2023/06/13/sentencing-cleveland-woman-convicted-driving-drunk-hitting-bus-stop-with-man-inside/
Actually, Landmark advertised on Indeed for emo
for that “people with criminal backgrounds encouraged to apply.” I have copy from last year. Crazy huh?
Criminal backgrounds should definitely not be a barrier to employment. Most people deserve a second chance. This usually requires one to take a position demonstrating their commitment to the position and the population served.
In a case like this, you have a less-than-three-year-old felony that earned a prison sentence and 10 years’ probation for the TOP POSITION IN THE BUILDING which means this felon will now be the face and spokesperson of that facility. Anything goes wrong: theft of property, staff who commit crimes/create problems, the patients leaving the building ASA or getting into trouble, etc. – all eyes turn to the ED who has the very recent felony conviction for almost killing a person due to the EDs inability to make good life choices.
This person could have been hired at a much lower visibility position. Landmark DOES employ people with criminal histories – no harm there. For an ED role like this, hell to the no.
Matt Boyle KNOWS he can’t get good talent at the top tiers. He’s scraping the crusty remains from the bottom of weeks-old garbage pails and calling it fine dining.
Ah well, doesn’t matter. Matt has a demonstrated history of making spur-of-the-moment decisions to fire people with no cause, no warning, no reason, all because his little brain tells him, “You’re a genius. Only you can make great decisions. Let’s just fire this person, no questions asked, no write-ups, no performance issues, show them the front door and hire someone else.”
He’s run out of good candidates. This was the best he could do.
When I worked for LR, I took three drug test. My third and final was never processed as LR failed to pay the vendor. Countless drug tests were tossed. I can’t see LR conducting background checks with the current financial situation. LR might out of business before the end of summer.