The Gabriel House assisted living facility did not perform fire drills or train workers in evacuation procedures and was also understaffed and poorly maintained, according to a current and former employee interviewed in the aftermath of the fatal fire there that killed nine residents.
“These people did not deserve what they got,” said Debbie Johnson, a certified nursing assistant who has worked at the Fall River facility for four years. “They did not deserve those living quarters that they lived in.”
The tragedy has renewed questions about the way the state regulates such facilities. Advocates for the state’s seniors said there are longstanding concerns about lax oversight of assisted living facilities, which offer some personal assistance but not the type of intensive medical care provided at nursing homes. The state Office of Aging and Independence, or AGE, oversees these homes.
Its powers and the scope of their responsibilities are limited compared to the expansive mandate the Department of Public Health has in its regulation of the state’s nursing homes.
“A full investigation is already underway,” Governor Maura Healey said in a statement Monday. “I know the people of Fall River are strong and resilient, and now is the time for us to all come together to support one another through this terrible tragedy.”
Dennis Etzkorn, the owner of the Gabriel House facility, did not respond to messages. He released a statement saying he was devastated by the tragedy and expressed thanks to those who responded.
A 33-page document from AGE, formerly the Department of Elder Affairs, dictates the certification procedures and standards for assisted living residences, which offer services like housing and meals for a monthly fee to adults who can live independently.
The standards set by the state often leave the specifics up to each facility, according to the document. Staffing levels must be “sufficient,” meeting a number determined quarterly by each residence, but there is no minimum staffer-to-resident ratio. Only residences that designated special care residences must have at least two staff members at all times.
Johnson said that two certified nursing assistants work throughout the night at the facility. At the time of the fire, about 70 residents lived there.
“Understaffed, that’s an understatement,” she said in an interview at the Timao Center, where displaced residents of the facility were gathered Monday. About 30 residents were injured, in addition to those who died.
According to the regulations, each residence is required to have an emergency preparedness plan for potential disasters like fires. The plans must include evacuation strategies and “shall address the physical and cognitive needs of residents.” Staff must also be trained on and periodically review the plans, although the frequency of those reviews is undefined.
Johnson said there were no fire drills or an evacuation plan.
Jenn Marley, a former Gabriel House certified nursing assistant, said she never experienced a fire drill while employed there for almost two years, and was never trained on evacuation procedures. She quit about three years ago, she said.
Marley recalled a home that was frequently understaffed and poorly maintained. New hires sometimes left within a matter of days after becoming acquainted with the residence’s conditions.
She remembered that some improvements, like painting over a large water stain near the main entrance, only happened when the facility received notice state officials would be visiting.
AGE last conducted an on-site compliance review at Gabriel House on Oct. 31, 2023, according to government filings. The agency cited Gabriel House for inconsistent documentation; late submission of 26 resident incidence reports; improperly stored medications; and three staff personnel files missing documentation of preemployment physical exams.
Gabriel House submitted a correction plan on Nov. 30, 2023, outlining how the facility planned to comply with state regulations. After reviewing the plan, the state issued Gabriel House a certificate that is good until November of this year.
More than 75 percent of Gabriel House’s residents are on MassHealth, the state’s Medicaid plan.
Legislation signed by Healey last year created increased oversight gatekeeping of the assisted living industry, requiring anyone with a 5 percent or more stake in a residence to provide a history of their involvement in residential care facilities and any history of mismanagement. The legislation also created the Assisted Living Residence Commission, an assembly of professionals, community members, and policymakers created to improve long-term care in the state.
“Their charge from the Legislature is to look at the assisted living industry and figure out what is going well and what needs to be addressed or reformed or corrected,” said John Ford, director of the elder law project at the Northeast Justice Center in Lynn.
A report from the commission to the Legislature is due Aug. 1.
AGE’s office that handles assisted living facility certifications is understaffed, said Clarence Richardson, executive director of the Massachusetts chapter of the National Academy of Elder Law Attorneys, an issue that’s been raised in conversations with the state office. The staffing numbers there are woefully inadequate, he said, to ensure the roughly 300 assisted living facilities in the state are being operated safely.
Facilities that fail to meet recertification requirements face inadequate penalties and can usually keep operating, Richardson said.
While the state could choose to modify, suspend, or revoke an assisted living home’s certification, financial penalties are a less severe response, and are just $500 for every day they operate without certification, he said. Suspensions can also prevent homes from admitting new residents, experts said. The fine amount is a pittance for homes that can charge thousands a month per resident. Gabriel House charges up to $2,400, according to its website.
Other advocates noted that building safety at assisted living facilities is usually regulated by local officials, not state authorities. The home’s most recent certificate of inspection through the city of Fall River is dated October 2024. Gabriel House was due for its next inspection this October.
Fire inspectors are typically excellent at ensuring a facility’s fire safety protocols are up to code, said James Lomastro, a member of the coordinating council for the Dignity Alliance, a Massachusetts senior advocacy organization, and a veteran of managing nursing facilities for seniors.
Local authorities, though, may not have the expertise to determine whether an assisted living facility will be able to evacuate residents, many of whom are likely to have physical or cognitive limitations during an emergency.
The Fall River Fire Department did not respond to a call seeking more information about their inspection process.
The state should assume some code enforcement responsibilities, he said, to ensure homes are conducting drills, have effective evacuation plans, and are staffed appropriately to meet the needs of residents who aren’t fully mobile.
“All that stuff is learned in drills,” Lomastro said, “and then you need someone to oversee making sure you’re doing it.”
Marin Wolf can be reached at marin.wolf@globe.com. Jason Laughlin can be reached at jason.laughlin@globe.com. Follow him @jasmlaughlin. Ava Berger can be reached at ava.berger@globe.com. Follow her @Ava_Berger_.