Exclusive: State suspended Gabriel House’s license years before fatal fire
The Fall River assisted living home, where 10 people were killed in a five-alarm fire earlier this month, was suspended by the state in 2016 from enrolling new residents, according to newly obtained documents.
Records from the Executive Office of Aging and Independence — then called the Executive Office of Elder Affairs — show a January 2016 incident of "resident mistreatment" prompted the state to temporarily suspend Gabriel House's assisted living certification.
The facility was allowed to continue operating, but could not enroll any new residents until the suspension was lifted.
In a letter informing Gabriel House of the suspension, Assisted Living Certification Manager Patricia Marchetti wrote the facility's failure to comply with state law regarding the incident in question "presents an immediate threat to the health, safety or welfare of its residents."
Gabriel House was required to submit a corrective action plan within 30 days or risk complete revocation of its assisted living certification. The state lifted the suspension on Nov. 14, 2016 — citing "evidence" of compliance with requested actions — and the facility resumed accepting new residents.
In the aftermath of the July 13 fire that tore through the horseshoe-shaped building at 261 Oliver Street, the conditions in the assisted living home and its management have come under scrutiny. State and city records — such as compliance reports, corrective actions and submitted complaints — show concerns dating back a decade-plus and include prolonged elevator outages, cockroaches, rodents and an absence of emergency and evacuation planning.
Gabriel House owner Dennis Etzkorn has not returned any of MassLive's requests for comments since the fire. When reached by phone Tuesday for this story, he said "no" and hung up.
Last week, Etzkorn released a statement through a spokesperson saying he would not be speaking to journalists while the investigation is ongoing.
Why Gabriel House's certification was suspended
According to state documents, the Executive Office of Elder Affairs received an incident report from Gabriel House on April 5, 2016, regarding a situation that occurred four months prior in January.
Specific details of the incident are redacted from the documents provided to MassLive. But they state that, on March 30, 2016, the "abuse, neglect or exploitation" incident was brought to the attention of Gabriel House's director of nursing. It involved a certified nurse's aid (CNA) in the facility's activity room with two residents.
The redacted incident report called it an "event with significant risk of serious physical or emotional harm."
A verbal warning was issued to the CNA without the knowledge of leadership, according to the records. When the director of nursing was informed on March 30, 2016, the "responsible" CNA, a student in a co-op program, was terminated.
The Executive Office of Elder Affairs determined that Gabriel House "does not substantially comply" with state regulations for certification procedures and standards for assisted living residences. On Sept. 12, 2016, it issued its suspension effective immediately.
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Gabriel House "has failed to ensure that its Residents are treated with consideration, respect, personal dignity, and privacy," the state wrote.
The facility was required to "transmit a notice of suspension" to each resident of the facility or their legal representative. The facility was also required to display a certificate of suspension in a "conspicuous place."
Gabriel House was given 30 days to comply with corrective actions issued by the state. The suspension was lifted on Nov. 14, 2016.
When the Executive Office of Elder Affairs was informed of the January 2016 incident, it was in the midst of a required compliance review, which the state conducts at all certified assisted living facilities at a minimum of every other year.
According to the results of the compliance review, dated March 9, 2016, Gabriel House was found to be running afoul of numerous regulations, including:
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Lack of documentation of resident medication lists
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Lack of a personal emergency response system for residents in need of emergency assistance
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No documentation of required training on abuse, neglect and exploitation for employees who began effective July 1, 2015
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The communication log did not document daily correspondence between staff members
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Not reporting incidents meeting criteria set forth by state law
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No documentation of fire drills conducted during the second and third shifts in the 2015 calendar year
Prior to the July 13 fire, the most recent compliance review for Gabriel House took place in October 2023 , at which time the state identified a number of violations, particularly when it came to proper and updated documentation of resident care.
After review and acceptance of Gabriel House's corrective plan, the state issued a certificate of operation in December 2023.
At the time of the fire, Gabriel House was up for recertification this November.
Deadly Gabriel House fire
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