Fire at Gabriel House, Assisted Living Facility

Globe Reports on Assisted Living Residences Commission

July 23, 2025: Boston Globe: Fall River fire prompts reconsideration of how Mass. regulates assisted living by Jason Laughlin and Kay Lazar.

“The blaze at Gabriel House, which killed 10 people and sent around 30 to hospitals, is prompting a state commission to address questions raised by the fire, including whether 7/24/25, 9:38 AM Fall River fire prompts rethink of assisted living regs including whether safety precautions at the state’s 273 assisted living residences and their staffing levels are sufficient to meet residents’ needs.

The Assisted Living Residences Commission is also considering whether the state should regulate the few facilities that cater to lower-income clients, like Gabriel House, differently from the majority that serve a wealthier clientele.

Spotlight: In Fall River, our promise to the elderly went up in smoke

July 19, 2025: Op Ed in Commonwealth Beacon by Richard T. Moore, Chair of Legislative Work Group

DignityMA’s Response to Governor Healey’s Statement on Safety in Assisted Living Residences

Download the entire DignityMA’s Response to Governor Healey (pdf).

July 18, 2025: Dignity Alliance Massachusetts (DignityMA) appreciates that Governor Maura Healey is requiring all 273 assisted living residences (ALR) in the Commonwealth to provide assurance that their ability to prevent and respond to emergencies such as a fire are current and up to regulatory requirements. By July 25, each provider must inform each resident and family member by letter about “fire safety protocols, evacuation procedures, and key points  of contact for questions or concerns.”

Additionally, within 30 days, each provider must provide assurance of compliance with all fire safety requirements. A site-specific Disaster and Emergency Plan must be submitted to the Executive Office of Aging and Independence (AGE), the state agency charged with overseeing and regulating ALRs.

On behalf of current and prospectives ALR residents, their families, and staff members, DignityMA is advocating that the following are taken into consideration during the assurance process:

• In addition to communications to current residents and families, all information is posted on the ALR’s  website. This is important for prospective residents and staff members’ knowledge as well as for advocates and the general public.
• All staff in all departments and all shifts are fully trained in prevention and emergency response procedures with 30 days.
• At least one fire drill per shift has occurred within the past 90 days.
• Conduct an assessment of each resident to determine their ability to “self-evacuate”. Identify the type of assistance likely needed for each resident unable to self-evacuate. Make this information available to staff and first-responding agencies.
• As part of the “compliance assessment regarding fire safety requirements”, determine if smoke barriers exist extending from the floor slab to the underside of the floor or ceiling above, or through a suspended ceiling to the slab above. Also, determine if bedroom and other occupancy rooms have self-closing doors when a fire alarm occurs.

Beyond these life safety aspects, DignityMA continues to advocate for:

• Transparency in ownership information. The names of owners (in addition to the Administrator) and full contact information should be readily available on the ALR’s website and posted publicly on the property as well as posted on AGE’s website.
• Copies of the results of all re-certification surveys are posted on the ALR and AGE’s websites and made available to residents and families.
• The work of the Massachusetts Assisted Living Residences (ALR) Commission continues until information stemming from the Gabriel House fire to be properly considered and there is opportunity for public input prior to the finalization of recommendations.
• A  comprehensive analysis is needed regarding the provision of “affordable assisted options” that are readily available, safe, and offer comprehensive services equivalent to other ALRs.

Governor Healey’s Statement on Safety in Assisted Living Residences

July 18, 2025: In response to the tragic fire at Gabriel House in Fall River on Monday, Governor Maura Healey today announced immediate steps to enhance the safety of residents living in Assisted Living Residences (ALRs). 

“What happened in Fall River is a horrible tragedy. Our hearts are with the families who lost loved ones and to the first responders who saved so many others,” said Governor Maura Healey. “This is a moment to make sure that every Assisted Living Residence is prepared to respond to emergencies and to protect the safety of their residents.”

Beginning Monday, July 21, the Executive Office of Aging & Independence (AGE), the state agency tasked with ensuring ALRs are in compliance with state regulations, will launch a statewide Fire and Life Safety Initiative to ensure all 273 ALRs in Massachusetts are prepared to protect residents during emergencies. These proactive measures build on existing work and reflect the administration’s commitment to transparency, accountability and partnership with providers, municipalities and families.

As part of the initiative, all ALRs must issue a letter to residents and families within five business days outlining fire safety protocols, evacuation procedures and key points of contact for questions or concerns. Additionally, ALRs are instructed to ensure evacuation instructions and exit routes are posted inside each resident’s unit and in common areas.

Furthermore, AGE will distribute a fire safety assessment survey that all ALRs must complete and return within 30 calendar days, reaffirming compliance with fire safety requirements such as sprinkler systems, fire drills, evacuation protocols and maintenance of fire-rated doors and walls. Providers will also report the age and key systems within their buildings to help prioritize oversight.

Finally, ALRs must also submit their current, site-specific Disaster and Emergency Preparedness Plan to AGE within 30 calendar days, concurrent with the Fire Safety Self-Assessment Survey.

“We are engaging every assisted living provider in this process. By requiring clear communication with residents and detailed reporting to the state, we are making sure resident safety is front and center – today and every day,” said Aging & Independence Secretary Robin Lipson. “Our entire team is committed to strengthening emergency readiness and improving standards across the assisted living sector in Massachusetts.”

“These immediate actions underscore our administration’s commitment to protecting our vulnerable populations. We are working closely with providers, local officials and families to put safety first and provide the peace of mind that residents deserve,” said Health and Human Services Secretary Kiame Mahaniah. “This coordinated response is about ensuring every building has the resources, knowledge and support they need to keep residents safe in the event of an emergency.”

ALRs in Massachusetts are subject to existing safety requirements under 651 CMR 12, including certification and recertification, compliance with building and fire codes, written emergency preparedness plans, staff training, and coordination with municipal emergency services.

AGE is also in the process of finalizing proposed amendments to strengthen regulatory requirements for ALRs. These proposed updates predate the Gabriel House fire but will be reevaluated in that context to ensure they meet current safety expectations.

AGE will issue detailed instructions to all Assisted Living Residences on Friday, July 18, outlining these new requirements and timelines.

Gabriel House Fire Synopsis:
Comprehensive Analysis and Policy Reform Framework

July 17, 2025: On July 13, 2025, nine residents died and 30+ were injured when fire swept through Gabriel House Assisted Living in Fall River, Massachusetts. The victims—ranging from 61-year-old Ronald Codega to 86-year-old Eleanor Willett—died in what Fire Chief Jeffrey Bacon called an “unfathomable tragedy.” This comprehensive analysis reveals the systemic failures that made this disaster not just tragic, but preventable.

Critical Failures Exposed

Dangerous Understaffing: Only two staff members were working overnight for 70 vulnerable residents. Survivors reported that staff “didn’t knock on one door” during the emergency, abandoning residents who needed assistance evacuating.

Maintenance Negligence: The building’s elevator had been broken for nine months, creating accessibility barriers that may have contributed to evacuation difficulties.

Regulatory Gaps: Gabriel House operated with minimal oversight compared to nursing homes, despite serving similarly vulnerable populations requiring significant assistance.

Questionable Ownership: The owner, Dennis Etzkorn, previously paid a $950,000 settlement to resolve kickback allegations related to his healthcare operations, raising questions about operator accountability.

The Federal Oversight Gap: A Two-Tier System

Recent Department of Health and Human Services Office of Inspector General (OIG) reports expose a fundamental policy contradiction. While nursing homes face extensive federal oversight—including minimum staffing requirements of 3.48 hours per resident day and mandatory data reporting—assisted living residences operate with virtually no federal standards.

An October 2024 OIG report found 236 life safety, emergency preparedness, and infection control deficiencies at 20 Massachusetts nursing homes despite heavy regulation. This suggests that lightly regulated assisted living facilities face exponentially greater risks.

The Human Cost of Regulatory Failure

The nine Gabriel House victims died in a facility that legally operated with staffing levels that would be illegal in a nursing home. The residents—many older, disabled, or requiring oxygen assistance—received less protection than nursing home residents despite similar vulnerabilities.

Gabriel House marketed itself as serving “seniors who cannot afford the high end of assisted living,” highlighting how economic vulnerability compounds safety risks when regulatory protection is inadequate.

The Economic Justice Imperative

Gabriel House’s mission to serve low-income seniors should not have meant accepting substandard safety. Reform efforts must ensure enhanced safety standards don’t price out vulnerable residents, requiring state subsidies or tax incentives to maintain accessibility while improving protection.

State and National Implications

With over 17,000 Massachusetts residents in assisted living facilities and similar regulatory gaps nationwide, the Gabriel House tragedy represents a national crisis requiring federal intervention. The current state-only oversight system has failed to protect vulnerable residents from preventable deaths.

Key Policy Recommendations

1. Federal Standards: Extend federal minimum staffing and safety standards to assisted living residences
2. Enhanced Oversight: Create assisted living equivalent to nursing home inspection and enforcement systems
3. Financial Transparency: Require public disclosure of finances, ownership structures, and safety records
4. Operator Accountability: Implement comprehensive background checks and ongoing monitoring of owners
5. Emergency Preparedness: Mandate nursing home-level emergency response capabilities and training

The Call for Action

The Gabriel House fire stands as a stark reminder that dignity, safety, and quality care cannot be achieved through market forces alone. Comprehensive regulatory reform is essential to prevent future tragedies and ensure that all residents—regardless of economic status—receive the protection they deserve.

The time for incremental change has passed. Massachusetts must act now to transform assisted living oversight and lead national reform efforts before more families experience the devastating loss witnessed at Gabriel House.

Sources: This synopsis is based on comprehensive analysis incorporating Wikipedia documentation, OIG reports, Massachusetts regulatory framework, news coverage, and Dignity Alliance Massachusetts advocacy materials. Complete source list available in full report.

Call to Action by Former State Senator Richard T. Moore DignityMA Legislative Workgroup Chair

The Fall River Assisted Living Fire Victims Deserve Meaningful Action

July 17, 2025: The 9 residents who died, the 30 who were injured, and all who lost their homes in the tragic assisted living fire in Fall River deserve to be remembered. Their sufferings will not be in vain if Massachusetts commits to reform and implements stronger regulations and more effective oversight of assisted living facilities and rest homes. The special commission currently working on assisted living reform must take strong action now if its efforts are to have any real meaning!

Dignity Alliance Massachusetts has proposed reforms such as licensing administrators, creating a board of registration to enforce regulations, set higher qualifications and ratios for staffing, training in fire and flood emergency response, setting meaningful financial penalties, making unannounced inspections, setting stringent rules for owners and operators, and many more. What happened in Fall River could happen in other long-term care facilities around the state unless such steps are taken, especially in places where residents have limited or no ability to self-evacuate.

The Massachusetts Assisted Living Commission, and the Executive Office of Aging and Independence are due to report on reforms by August 1. However, if more time is needed to incorporate lessons learned from the Fall River tragedy, the study should be extended as necessary. Then the Healey Administration and the Legislature should take immediate action to implement common-sense, meaningful reforms that focus truly on quality and safety of assisted living residents over profits of facility owners.

Older adults, especially those who are physically, cognitively, and financially challenged, need and deserve a home that is affordable, accessible, safe, and that serves their care needs.

Massachusetts needs to get it right and do it now!

Commentary by James A. Lomastro, PhD, Chair, DignityMA Facilities Workgroup

July 17, 2025: The Gabriel House tragedy starkly illustrates the dangerous reality of Massachusetts’s two-tiered assisted living system. While affluent seniors access high-quality care, middle- and lower-income residents are relegated to facilities operating under financial constraints that compromise safety and dignity.

Massachusetts’s average monthly assisted living cost of $6,500 creates fundamental inequity. Medicaid’s inadequate coverage forces seniors into nursing homes—more restrictive and expensive than necessary—simply because it’s the only option covered. Meanwhile, middle-income seniors face a cruel choice: deplete life savings to qualify for Medicaid or forgo appropriate care entirely.

This system failed the nine residents who died at Gabriel House. Financial pressures that led to operating with only two overnight staff for 70 residents represent systemic failures, not isolated incidents. When facilities market themselves as serving “seniors who cannot afford high-end assisted living,” we create conditions where economic accessibility comes at the cost of basic safety.

Massachusetts must act decisively. We need a middle-income support program with sliding-scale subsidies, ensuring assisted living isn’t exclusively for the wealthy or destitute. The state should dramatically expand Medicaid waiver programs and streamline applications. Following successful intellectual disabilities housing models, we should use public financing and private partnerships to develop quality assisted living for middle-income and subsidized residents.

Veterans deserve special attention—existing bonds should fund assisted living specifically for those who served our country. Additionally, providers must track and report access data by income, race, geography, and Medicaid status to ensure transparency and accountability.

The Gabriel House victims deserved better. Without addressing affordability’s role in creating unsafe conditions, we risk more preventable tragedies. Massachusetts must lead in creating a system where financial status doesn’t determine safety and dignity in assisted living.