In 2018, Timberline Knolls, an upscale mental health center for women that once attracted pop stars like Demi Lovato, was in trouble. At least four residents said a therapist had sexually assaulted them on the facility’s wooded campus outside Chicago.
The therapist was arrested, and the center’s corporate owner, the large national chain Acadia Healthcare, said it had made changes “to assure that it won’t happen again.”
But dangerous conditions persisted for years at Timberline Knolls, an investigation by The New York Times found, in part because of pressure to enroll more patients without hiring enough employees.
Two former residents sued Timberline Knolls last year, claiming that an aide had raped them. Acadia had hired the aide despite a criminal record that included domestic violence and gun charges.
Another resident — a child who was a ward of the state — nearly died after she overdosed on medication that had been left out in a common area, according to former staff members. And two other women died by suicide after being left unsupervised, a rare occurrence at mental health facilities.
“We were extremely understaffed,” said Cecilia Del Angel, who worked as a behavioral health aide at Timberline Knolls until last July. Several other former employees echoed that sentiment. The patient deaths, Ms. Del Angel said, were “entirely preventable.”
Acadia this year closed Timberline Knolls — which the company’s chief executive once called a “shining star” — after a “comprehensive review” of its services.
Illinois regulators had not looked into the suicides. A spokesman for the state’s health department said it did not regulate Timberline Knolls, and the state’s Division of Substance Use Prevention and Recovery had not visited the property since 2019. Those oversights allowed Acadia to skirt accountability despite caring for people at heightened risk of harming themselves or others, The Times found.
In response to The Times’s findings, the substance abuse agency said it was “deeply concerned about the alleged conduct at the facility” and would be “conducting a review to assess whether additional measures could have been taken.”
Tim Blair, a spokesman for Acadia, said in a statement that the company had a zero-tolerance policy for behavior that could put staff or patients in danger. “We reject any notion that we put profits over patients,” he said, adding that “complaints and incidents are investigated and addressed.” He said surveys had found that most Acadia patients were pleased with their care.
Mr. Blair denied that Timberline Knolls had dangerous conditions and said it had adequate staffing levels. He said that industry accrediting groups had repeatedly inspected the facility and that all employees had undergone “extensive background screening.”
The problems at Timberline Knolls were part of a nationwide pattern of lapses at Acadia, one of the country’s largest for-profit providers of mental health services, with more than 260 facilities in 39 states, The Times found.
Acadia has closed facilities over the past decade after reports of sexual abuse. More than a dozen patients reported sexual assaults at an Acadia psychiatric facility in Utah. At a youth treatment center in New Mexico, patients claimed that staff had sex with them and pushed them to participate in “fight clubs.” And in Michigan, three women said they had been sexually abused by a supervisor at a youth treatment center.
The Times reported last year that at many of its psychiatric hospitals, Acadia held patients against their will to maximize their insurance benefits. And the company’s chain of methadone clinics — the country’s largest — billed the government for services, like counseling, that it did not provide. Federal prosecutors and regulators have opened multiple investigations into the company.
Spanning 43 acres in Lemont, Ill., Timberline Knolls cared for women and girls with eating disorders, mental health problems and drug addiction. Over the years, the facility served about 26,000 patients, including the pop stars Kesha and Ms. Lovato.
Some spent weeks or months there. The center also had a contract with the State of Illinois, bringing in nearly $2 million since 2021 to treat seven children in foster care, according to the state’s Department of Children and Family Services.
In the summer of 2018, patients complained to Timberline Knolls employees that a therapist, Michael Jacksa, had sexually abused them on Timberline’s campus. The facility waited more than three weeks to call the police, doing so only after the patients complained to the state’s substance abuse agency, court records show.
Timberline’s leader at the time, Sari Abromovich, said an Acadia executive had told her not to alert the authorities, according to a deposition she gave in a lawsuit later filed by one of the women who was raped. (The lawsuit was settled for an undisclosed amount.)
Ms. Abromovich, who was fired in 2018, said she was under daily pressure from corporate managers to fill beds and keep expenses low by skimping on staff.
Mr. Jacksa later pleaded guilty to sexually abusing patients. He and his lawyer did not respond to requests for comment.
“We were deeply troubled by Mr. Jacksa’s predatory behavior and made changes to policies and the campus environment,” said Mr. Blair, the Acadia spokesman. He disputed Ms. Abramovich’s characterizations.
Patient enrollment fell with the news of Mr. Jacksa’s arrest. In the ensuing years, Acadia pressured staff to find new ways to fill beds, according to eight former employees, who spoke on the condition that The Times not publish their names because they still work in the mental health industry.
Recruiters told prospective customers that Timberline’s treatment options included horseback riding, even though the facility no longer offered that service, according to former patients and employees. Timberline began accepting patients with more serious conditions, like autism and dementia, who previously would have been turned away because they needed more intensive care, former employees said.
Mr. Blair denied that Acadia had pressured employees to admit patients improperly, noting that Timberline Knolls “turned away hundreds of patients a year who did not meet clinical admission criteria.” The company was “transparent with prospective patients and families” about the facility’s services, he said.
Staff struggled to prevent patients from fighting, harming themselves and escaping the facility. In 2020, the Lemont police were called to Timberline Knolls 222 times, police said. By 2023, that number had soared to 519. No one else in Lemont made more emergency calls.
Mr. Blair said the volume of calls to the police “is not correlated to facility staffing levels, care quality or overall conditions.” Timberline Knolls’ policy, he said, was “to err on the side of caution and to call police even if the situation didn’t mandate or require it.”
In 2023, Timberline Knolls hired Erick Hampton as an entry-level patient aide. Nine years earlier, he was charged with domestic battery after his girlfriend said he had dragged her out of the house by her hair, according to arrest records. (The charges were dismissed after she did not show up in court.) In 2020, he was arrested on a gun possession charge and pleaded guilty to a lesser charge.
Mr. Hampton did not respond to requests for comment.
Several co-workers said Mr. Hampton had unnerved them by commenting on their bodies and making other inappropriate remarks. He sent one colleague sexually explicit messages on Snapchat, saying he wanted to choke her, according to a screenshot the woman shared with The Times.
In March last year, Mr. Hampton pulled an 18-year-old resident, J.P., into a room without cameras, forced his hands up her shirt and grabbed her breasts, according to a lawsuit she filed in October. Later that spring, she claimed in her lawsuit and a police report, Mr. Hampton led her into an office and tried to force his hands into her underwear.
In an interview with The Times, J.P. said that she had told two Timberline employees, but that nothing had changed. She did not believe she could leave the facility; her mother had insisted that she enroll after she attempted suicide. (J.P. asked to be identified by her initials, which are also used in the lawsuit, because she said she was a victim of sexual assault.)
Soon after, J.P. was admitted to a nearby psychiatric hospital for reporting suicidal thoughts. When the hospital released her a few days later, J.P. said, Mr. Hampton was waiting for her in the parking lot. He drove her to his duplex apartment in Gary, Ind., about an hour from Timberline Knolls.
J.P. said she saw guns in the apartment and felt terrified. She stayed there for more than a week, and Mr. Hampton raped her repeatedly, according to her lawsuit.
On April 26, after J.P. downed some pills and a bottle of alcohol, an ambulance arrived and took her to a nearby hospital, according to J.P. and police records. J.P. then returned to Timberline Knolls and recounted the story, which spread quickly among the staff, according to former employees.
In a brief telephone call with The Times, Eiliana Silva, the director of J.P.’s residential unit, acknowledged that she had heard concerns from staff about Mr. Hampton but said she could not properly supervise him because she was one of only two directors overseeing five lodges. As soon as she heard about J.P.’s complaint, she said, she relayed it to Timberline Knolls’ leadership.
In May, records show, a Lemont police officer went to Timberline and interviewed J.P. That officer referred the case to the Gary police, who did not pursue it until February, after The Times asked about the incident. A captain at the Gary Police Department said the investigation is still open.
The Lemont police chief said the department is investigating claims that Mr. Hampton assaulted J.P. while she was at Timberline Knolls.
Mr. Blair said that “upon learning of the troubling allegations against Mr. Hampton, police were promptly contacted, Mr. Hampton was terminated, and we cooperated with investigating authorities.”
In August, another former resident sued Timberline Knolls, claiming that the facility had failed to protect her from being raped by Mr. Hampton. (The woman, who is represented by the same law firm as J.P., declined to comment.)
At the time Timberline Knolls’ leadership heard the accusations against Mr. Hampton, the staff was still reeling from three other disasters.
In January 2023, Tiley McQuern, 50, was found dead in her bed after swallowing too many pills. A staff member told police that although employees were supposed to check on patients, those checks were “not thorough,” police records show. Ms. McQuern’s husband has filed a lawsuit against Acadia for wrongful death.
Seven months later, a child, who had been placed at Timberline Knolls by the state’s child welfare agency, was rushed to the hospital after overdosing on medication that a staff member had left in a common area.
Then, in May 2024, another resident, 20-year-old Deborah Cobbs, threw herself down a staircase while no one was supervising her and died. She had tried to escape Timberline twice that day, police records show. Ms. Cobbs had also told several people that she was feeling suicidal, according to former employees who worked there at the time.
Her mother, Sherilvon Moultrie, told The Times that she was still in disbelief. “Who was watching her?” she said. “How was she able to do what she did?”
Suicides at mental health facilities happen rarely, and when they do, they are typically investigated by state health authorities to determine how to prevent such incidents from happening again. But Illinois did not investigate either of the suicides, according to a review of inspection records.
Timberline Knolls fell into a regulatory gray area. It was not subject to regular inspections by the state health department, which oversees hospitals and nursing homes, or by the substance abuse agency. The state does not regulate facilities that treat eating disorders, said Michael Claffey, a spokesman for the health department.
“We are actively working with subject matter experts in our relevant state agencies to determine the appropriate state oversight for such facilities,” Mr. Claffey said.
The only agency that frequently visited Timberline Knolls was the child welfare agency. Those visits were to check on the safety of the seven children the agency had placed there, not to evaluate broader conditions for all patients.
That agency’s spokeswoman, Heather Tarczan, said it had required Timberline’s staff to get additional training on safeguarding contraband after the child nearly died. The agency stopped placing children at Timberline last fall.
If you are having thoughts of suicide, call or text 988 to reach the National Suicide Prevention Lifeline or go to SpeakingOfSuicide.com/resources for a list of additional resources.
Susan C. Beachy contributed research.
Jessica Silver-Greenberg is a Times investigative reporter writing about big business with a focus on health care. She has been a reporter for more than a decade.
Katie Thomas is an investigative health care reporter at The Times.
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