Assisted-living facility where 10 died in fire loses certification over mistreatment

Background on Gabriel House and Previous Issues

A Massachusetts assisted-living facility where a tragic fire claimed the lives of 10 people earlier this month had previously faced serious issues that led to the temporary loss of its certification nearly a decade ago. According to state regulators, the facility failed to treat residents with "consideration, respect, personal dignity and privacy." Specific details about the reasons for the monthlong suspension were redacted in documents provided by the state Executive Office of Aging & Independence. At the time, the facility in Fall River was prohibited from accepting new residents until it implemented corrective measures.

This incident adds to a long list of concerns raised about Gabriel House over the years. A recent lawsuit filed by a resident alleged that the facility was not properly managed, staffed, or maintained, and that emergency response procedures were lacking. Another resident’s son mentioned that an elevator had been out of service for up to nine months at one point.

The State's Role and Regulatory Gaps

The deadliest fire in the state in over four decades has brought attention to the lack of comprehensive regulations governing assisted-living facilities, which often serve low-income or disabled individuals. Governor Maura Healey has not commented on the effectiveness of state and local inspections but has highlighted that a state commission is working on recommendations to improve these facilities.

State records released Tuesday included about two dozen complaints about the facility over the past decade, many involving abuse, neglect, or financial exploitation. Details were redacted, but some specific cases were highlighted. These included a resident who was stuck in an elevator for hours, followed by months of downtime. Other complaints involved staff members threatening residents and withholding medication. There were also reports of a nurse withholding medication, environmental safety issues, and a cook described as "obsessive, controlling and abusive."

Detailed Complaints and Resident Experiences

One of the most detailed complaints came from 2015 and appeared to be written or dictated by a resident. It listed over a dozen issues, including bed bugs, roaches, over-medicated residents, and fist fights in common areas. The complaint stated, “It is a place where you can’t feel safe due to other patients and corrupt staff. The staff treat the people there very cruel and show no respect for them or their needs.”

Dennis Etzkorn, the owner of Gabriel House, has chosen not to speak to journalists and is instead focusing on supporting the families of the victims and cooperating with the ongoing investigation into the fire.

Ongoing Elevator Problems and Calls for Action

Recent documents revealed that state officials were concerned about the ongoing elevator issues as early as spring 2025. A field supervisor with Massachusetts’s long-term care ombudsman expressed alarm in February, urging the state to investigate the faulty elevator at Gabriel House. He noted that every time he raised the issue, he received excuses. An unnamed official wrote to the office’s assisted living certification specialist, saying, “Please call this place and see if this is true … if so we need a remedy /plan asap.”

Etzkorn later provided a timeline of the elevator problems, stating that work would begin in March after the issue was first reported in September 2024.

Compliance and Recent Violations

Before the July 13 fire, the most recent compliance review found numerous repeat violations, many related to record keeping. After submitting a corrective plan, the facility was granted renewed certification in December 2023.

Investigators have indicated that the fire likely started unintentionally, either due to someone smoking or an electrical issue with an oxygen machine. The blaze left some residents hanging out of windows and screaming for help.