The teenager had been too sick to join in a hike one day last January while staying at Maple Lake Academy — but the program’s recreational therapist, state officials say, didn’t believe the girl.
“You don’t know what pain is,” the staffer told her, according to multiple interviews conducted by state licensors. The woman yelled at the girl, witnesses told investigators, and belittled her.
The teen died a week later — after she was not given proper medical care at the Utah youth treatment center, licensors say, despite her worsening symptoms and her parents’ repeated requests that she be taken to a doctor.
Maple Lake Academy would lose its license, state regulators decided in May, after the girl died in January and another girl did not get immediate medical care after she hit her head on pavement in April. It was a rare move for the Office of Licensing, which has been criticized for light oversight that has contributed to Utah’s booming teen-treatment industry.
But regulators backed down this week.
Instead of arguing to an administrative law judge that Maple Lake Academy should be shut down, as expected, licensors instead reached a deal with the facility that keeps it open.
A corrective action plan released to The Salt Lake Tribune this week includes new details surrounding the girl’s death in January, including that a staff member reported that they heard the girl “moaning, groaning and breathing rapidly” throughout the night before she died — and did nothing.
Deputies were called to the facility on the morning of Jan. 16 for a medical issue, according to police. Staff at the facility had started CPR after calling dispatchers, but the girl died after being taken to a hospital.
Her cause of death — and her identity — have not been publicly released.
Some former Maple Lake Academy residents say they are devastated that the center can stay open after the failures to seek care for both girls. They have been urgently trying to share their own experiences of what they felt was mistreatment and medical neglect as the date of this week’s appeal hearing approached.
A half dozen former residents or staff told The Salt Lake Tribune in interviews that they were not surprised when they learned a girl had died while staying in the small Spanish Fork program — which caters to teenagers who have autism, anxiety, depression and certain learning disabilities.
“To see that a child died because of medical neglect — I knew they had done that [ignored requests for care] to other students,” said Michaela Granger, who spent two years at Maple Lake Academy beginning in 2014. “They’d done it to me.”
The former residents started social media campaigns, created an online petition and compiled pages of testimonials, videos and photos that they sent to state licensors in the past few weeks, hoping their stories could be used by Utah officials in the effort to shut the program down.
They wanted Utah regulators to listen to them and believe them, they say. But with the state allowing Maple Lake Academy to remain open, they don’t feel heard.
“Does this mean that another child has to die?” Granger wondered. “We’ve been fighting so hard for people to listen to us. A death isn’t enough. What will be?”
‘Walking in the right direction’
Simon Bolivar, director of the Office of Licensing, said in a statement this week that the agency’s goal is to work with providers to “make sure the health and safety of vulnerable populations are protected.” That work, he said, includes helping centers comply with state rules and assisting them on “paths for correction.”
“If the [Department of Health and Human Services’] Office of Licensing determines that the provider is walking in the right direction, our job is not to close them but to support their efforts to become better providers,” he said, “as long as the health and safety of their clients are not compromised.”
Bolivar wasn’t the director at the time the state announced it would revoke Maple Lake Academy’s license.
Mike McDonald, who was in charge of the division three months ago, said then that it was necessary to revoke the license because of the “similar failure” to seek medical attention for the girl who died and the second girl who was injured in April.
Maple Lake Academy administrators said in a statement that they were “gratified” that they instead reached a resolution with the state.
“It is possible,” they said, “to have disagreements and still work together toward the mutual goal of making sure that our students are safe and healthy. We understand that state regulators have the well-being of our students as their first priority, as do we.”
The state opted to put Maple Lake Academy on a corrective action plan — which by definition, under state rules, is not considered a penalty — and will monitor the facility for the next year, according to the program’s attorney.
In the plan document, licensors say they discovered that Maple Lake Academy had provided documentation showing staff had done 15-minute checks through the night before the girl died. But a staffer told investigators that workers hadn’t done the checks and had been asleep from about 12:30 a.m. to 4:30 a.m.
Licensors also found that the recreational therapist who yelled at the sick girl had a history of “yelling at, cursing at and physical aggression with clients.” She also called clients what is known as the R-word, a slur for those who are intellectually disabled, investigators found.
Maple Lake Academy told the state that the recreational therapist is no longer employed there.
State Sen. Mike McKell, who in 2021 sponsored a bill that brought increased government oversight to teen treatment programs, said Wednesday that he is “incredibly frustrated” that Maple Lake Academy kept its license.
“It is one of the most egregious cases of medical neglect that I’ve seen in the country,” the Republican lawmaker said. “You had a young girl who is terminally ill, and instead of getting her treatment, they treated her poorly and basically accused her of faking it to get out of hikes.”
McKell said he realizes now that his reform bill did not include adding a strong revocation process. He wants to work with the Office of Licensing to create a “tier” system, where certain violations — like a child’s death — would result in a program automatically losing its license.
“I think the facility still needs to answer for what happened,” he said, “and justify why they should be able to take care of kids.”
‘Students weren’t taken to the doctor’
Former residents who were at Maple Lake Academy over the last decade told The Tribune that they felt their requests for medical care weren’t taken seriously, or they saw other residents who didn’t get the help they needed.
Reagan, who is being identified by a pseudonym, said she remembers feeling abandoned by her parents after she was sent to Utah in 2013 at age 15.
The Tribune verified the attendance of former residents at Maple Lake, and is identifying some by only a first name or by pseudonyms because they fear that speaking publicly about their medical history and treatment could affect their jobs or future prospects.
Reagan recalled her therapist telling her that her family had sent her across the country to a wilderness program, then to Maple Lake Academy, because they didn’t want her.
She didn’t know until years later that her parents had frequently called to check in with her — a call log confirmed it. But none of the staff told her that they were trying to contact her, she said.
After months in the program, Reagan remembers, Maple Lake Academy staff agreed that she could taper off an antipsychotic medication that she had been prescribed before she got there. The change in medication made her feel anxious and she remembers crying constantly.
The staff, she said, began giving her the sedative clonazepam in response. She remembers feeling groggy one July afternoon when a staffer told her to ride a horse, and it threw her off.
“They said it was my fault because I was too anxious,” she said, “because she’s usually a pretty mild horse.”
Reagan shared her medication log with The Tribune. It shows she was given clonazepam the day before a “horse accident” was noted, for which she received ibuprofen.
She said she asked to go to a hospital to balance out her medications, but staff refused and told her parents going to a hospital would be too traumatic for her.
Instead, she was given more clonazepam and was put on “mattress,” she said, a protocol at Maple Lake Academy where students are forced to wear oversized scrubs and sleep on their mattress in a hallway.
“I was basically just sleeping, like, 24 hours,” she said.
Maple Lake Academy administrators agreed to end its practice of having youth sleep on mattresses in group areas, according to the corrective action plan released this week, and children instead will sleep in their own rooms or a “safety” bedroom.
Granger said she remembers seeing Reagan’s reactions to her medication change and how she ended up sleeping in the hallway. And she saw other fellow residents not getting medical care they requested, she said. If they did ask for help, she said, the staff’s frequent first response was that they were lying.
“Students weren’t taken to the doctor right away when they had illnesses,” she said. “That’s not the first thing they did. [They would ask,] ‘Is it really that serious? Let’s monitor you first.’ It didn’t matter what it was.”
Staff who were ‘hesitant’ to seek medical care
Ted, who is being identified by a pseudonym, said he was frequently misgendered while at Maple Lake Academy in 2018, where his therapist would often say he needed to “find your inner femininity.”
He knew he was transgender from an early age, he said, and his parents had agreed that he could have an IUD implanted when he was 13 to stop his period, which he felt was distressing and caused gender dysphoria and mood swings.
It was supposed to be removed when he was 15 years old, he said, which is when he was living at Maple Lake Academy. But when he asked about it, he said the program nurse told him she had consulted with her husband, who is an OB-GYN, and said it would be fine to leave it in place.
“He’d never seen me,” Ted said. “I wasn’t his client. Because of that, I didn’t get it taken out.”
When Ted went to have it removed a year after he left Utah, it required surgery because the copper IUD had embedded in his uterine lining as his body grew, he said. His medical records from that time show an annotation that he was “two years overdue” in having the IUD removed.
“I had to have invasive surgery,” he said. “It put me out of work for a week.”
Ciara, who The Tribune is identifying by her first name, said she went to Maple Lake Academy in 2011, as a 13-year-old girl who was bullied at her school and was struggling with dyslexia.
She remembers the girls would do labor, like building fences or gardening, at staff members’ homes, and she shared journal entries and photographs from that time that showed girls working on a “service project,” raking a property that neighbored a staff member’s home.
Ciara tearfully described a night when her roommate had returned from watching “The Last Airbender” at a movie night. She was dancing and practicing the moves in their bedroom when Ciara heard a pop and the girl fell to the floor crying. She had hurt her knee, Ciara said, but the staff told her to go bed.
“I just remember her screaming and crying the entire night,” she said.
The next morning, she saw that her roommate’s mattress had been taken out of their room and the girl was sleeping in a common room. Ciara said she noticed the girl’s knee was swollen and black.
The girl was taken to a doctor later that next day, and Ciara shared a photo that showed her roommate in crutches.
Remembering how the girl screamed in pain through the night still affects Ciara.
“They were always so hesitant to take girls to the doctors,” she said.
Maple Lake Academy responds
When asked to respond to allegations of previous medical neglect, Maple Lake Academy administrators said in a statement that they treat young people with “specific mental and emotional profiles” that can be challenging.
“It is the nature of the work we do that not every client will leave happy,” the statement reads. “We are disappointed when a former student expresses discontent, but it does not dilute the satisfaction we get from our far more numerous successes. Many young people we have helped over the years have gone on to be doctors, teachers, hold professional careers, and have healthy relationships, for some including raising their own children. Many keep in contact and give us updates on their lives, and even stop by to visit when they are in town to catch us up on what they are doing.”
“It is easy,” administrators added, “for outside critics — who have no firsthand knowledge of the work we do — to ignore the many in order to focus on the few.”
The Tribune spoke with parents of two girls who are currently at Maple Lake Academy, and is not identifying the adults to protect the girls’ medical privacy. They live on opposite sides of the country, but shared similar stories of how they felt Maple Lake Academy was the best place for their children, both of whom have autism. They said their children are thriving now in a program that specifically addresses their needs.
“It’s been nothing short of amazing. I don’t recognize my child that I sent to Utah,” said one mother, whose 17-year-old is currently enrolled. “She’s happy, she’s healthy. She still has her learning challenges and trauma, [but] it’s in control now to the point where it can be managed.”
The mother said her child will soon be transitioning out of Maple Lake Academy to another school with less restriction that is closer to home. She said she feels people often think parents who send their children to programs like Maple Lake Academy don’t care about their kids — but nothing could be further from the truth.
“There’s a lot of judgment right now about parents who send their kids away,” she said. “That’s not the case. There’s really nowhere else for them.”
The father of a 13-year-old resident said he and his wife analyzed whether it was safe for their child to stay at Maple Lake Academy after the girl’s death in January.
But it wasn’t safe for her to be at home, he said, which is why they sought treatment. “She’s safer there than anywhere else,” he concluded.
The father said his daughter has received prompt medical care this last year, for everything from visiting an orthodontist to monitoring after she had a headache from taking a hard dive into a swimming pool.
He’s been worried these last few months about what could happen if the state did shut the program down, he said. He feared his daughter would lose the progress she made if she had to restart a program and learn to build trust again with her therapist and the program staff.
“Home is not the de facto solution you think it would be,” he said.