SPRINGFIELD — The competition was fierce among dragons along the Connecticut River on Saturday.

The battle was between canoes in the 11th Springfield Dragon Boat Festival, which saw pencil-like boats operated by teams that gathered at North Riverfront Park.

For weeks at a time, assisted living residents in wheelchairs on the top level of Gabriel House couldn’t leave their floor, trapped by a broken elevator that management wasn’t in any hurry to fix.

Because they couldn’t make it downstairs to the communal dining room, meals were brought up to them. Medical appointments were often missed because there wasn’t any means of egress.

And because they couldn’t go outdoors, residents in wheelchairs who smoked cigarettes or cannabis often did so in their studio-style rooms.

In the aftermath of the July 13 fire that ripped through the Gabriel House in Fall River and killed at least nine residents, MassLive interviewed multiple people — residents, family members, current and former employees — who detailed the third-floor confinement at the assisted living facility during prolonged elevator outages.

It’s one example of unsettling conditions at the former motel-turned-assisted living facility in the blue-collar city’s Kennedy Park area.

They also described sanitary and safety issues that trace back years, including rodents, cockroaches and a perceived absence of emergency planning, corroborated by state and city records.

Fall River Fire Chief Jeffrey Bacon has said fire drills were conducted at the assisted living facility for staff members, but current and former residents and employees said they haven’t participated in an emergency drill in at least four years.

“No fire drills, we didn’t do anything … no practices,” Debra Johnson, a certified nursing assistant and employee for the past four years, told reporters the day after the fire.

• Read more: Fall River funeral home offers free services for Gabriel House fire victims

The son of Alvaro Vieira, a 64-year-old resident injured in the fire, said his father recalls one fire drill about five years ago, but none since.

His father has “been having problems the last couple years … it’s really obviously one of the cheaper nursing homes,” Chris Vieira, 33, of New Bedford, said.

A former employee who agreed to speak with MassLive under the condition of anonymity said there weren’t any drills at the facility. She said residents “deserved better care” and that the building was like a matchbox.

“We’ve always said it’s in that spot — ready to go up. That if somebody starts a fire, there’s going to be an issue,” the former employee said.

Despite the reported conditions, residents and staff members described the community at Gabriel House as one where people looked out for and cared for one another. One employee wrote in a Facebook post that, “If you were lost and had nowhere to go, you had Gabriel House.”

Anthony Hout lived there from 2017 to 2022. He said the caring staff members “loved us to death,” but any time something was reported to the higher-ups, “it just got blown off. They ignored everything we said to them.”

Messages left for Gabriel House owner Dennis Etzkorn have not been returned. One person who answered the phone said, “Not available,” and quickly hung up when a reporter identified themselves.

Etzkorn faced legal troubles more than a decade ago with a different company, unrelated to safety concerns, including criminal charges in 2012 for a suspected Medicare kickback scheme involving his company, Gabriel Care.

The case was dropped after the court ruled prosecutors had illegally obtained evidence, and key evidence, such as caregiver testimony, was deemed inadmissible. Etzkorn reached a $950,000 settlement with the Attorney General’s Office in 2015 in exchange for the charges being dismissed.

1/9

Elevator outages would last months

Multiple people told MassLive the building’s elevator would consistently break down and not be repaired by management for weeks to months at a time — most recently, for more than six months.

While people on the second floor could access the ground level via a ramp, residents with limited mobility on the third floor were effectively stuck.

Those who couldn’t take the stairs would miss doctor’s appointments, the former employee said.

“That elevator, it was every year. There was a problem with that elevator every single year. It was really bad,” said Chris Vieira.

• Read more: Deadly Fall River fire exposes long-simmering dispute over department staffing

Terry Leuvelink, whose 86-year-old mother, Eleanor Willett, died in the fire, recalled the elevator being down for “eight months” at one point. Living in walking distance, she visited often, sometimes sleeping on Willett’s floor on a blowup mattress.

Third-floor residents with mobility challenges were unable to come down to the dining room, Leuvelink said, so staff would bring meals to their rooms.

“They couldn’t go outside to smoke their cigarettes, so that’s why people were smoking in their rooms,” she said.

Under Massachusetts law, buildings open to the public and multi-family residences, such as the Gabriel House, must have elevators inspected annually. Building owners can be fined if they fail to comply with the regulations.

According to the Americans with Disabilities Act, elevators can be afforded temporary and isolated disruptions, but building owners are expected to repair them promptly.

Details remain unclear about the Gabriel House elevator’s inspection history and response to recent outages. A Seekonk-based company, believed to have serviced the elevator, did not return requests for comment.

MassLive has requested state inspection records from the Board of Elevator Regulations but has not yet received them.

Sanitary and care management concerns

Many who lived at the Gabriel House didn’t have close family members and required a lot of assistance with mobility and medical needs, the former employee told MassLive.

At a typical assisted living facility, residents receive multiple meals a day with limited medical and home care provided. Generally, people residing in assisted living have a level of independence and don’t require the significant 24/7 medical attention provided by nursing homes.

At Gabriel House, the lines were blurred.

Paul Lanzikos, co-founder of the Dignity Alliance of Massachusetts and a former state secretary of elder affairs under Gov. Michael Dukakis, said it appeared that many of the people residing at Gabriel House could not “self-evacuate,” meaning they likely required higher levels of care than what is provided in assisted living.

• Read more: Body cameras show rescues as fire tore through Fall River assisted living facility

Body camera footage released by the city from the night of the fire showed police officers and firefighters carrying numerous people using wheelchairs, scooters and walkers down multiple flights of outside stairs or ladders, signaling that they resided on the upper floors.

The sanitary conditions at the facility were also concerning, multiple people told MassLive.

Many studio units were in disrepair, with some featuring stained rugs and others electrical wires hanging from gaping holes in bathroom ceilings.

“It was cockroach-infested. Bed bugs, mice. The rooms were filthy,” Johnson said.

Records provided to MassLive by the Fall River Department of Health and Human Services include several invoices from 2024, 2020, 2015 and 2014 for treatment of bed bugs and extermination of mice, rats and cockroaches by local pest control companies.

The records also include complaints made to the city. In February 2020, one Gabriel House resident complained of “bed bugs moving from one room to another.”

Another complaint, sent to the city in September 2014, cited bed bugs, undercooked food and a “filthy” dining room.

Fall River Mayor Paul Coogan told MassLive that the city didn’t receive a noticeable number of complaints from Gabriel House compared to all the complaints they receive across the city. He was unaware of the conditions being reported after the fire.

“No one is more feeling guilty for these people than me, for what happened to them and from the descriptions of what went on in there, but I didn’t know a thing,” Coogan said.

• Read more: ‘I’m lucky I’m alive’: Fall River residents recount fatal fire at assisted living facility

Leuvelink, the daughter of Eleanor Willett, said their first tour of the Gabriel House was “scary” and “not impressive at all.” But it was affordable compared to other assisted living facilities they’d visited, and Willett was just happy to have a roof over her head close to family members, she said.

The average monthly cost of assisted living in Massachusetts ranges from $3,655 to $8,036, according to the Executive Office of Aging and Independence. At Gabriel House, residents were charged between $1,850 and $2,400 a month.

Leuvelink recalled the building smelling like urine. She cited old rugs and a ripped couch in the main sitting room. Before her mother moved in last July, her studio unit was renovated, which pleased the family.

But then Willett began to see the mice and cockroaches.

“She couldn’t sleep,” Leuvelink said. “And she was scared to death. She thought they were going to climb in her bed with her.”

Leuvelink bought some BugMD spray and put out cotton balls soaked in peppermint oil in her mother’s room. The Gabriel House also installed “sticky mouse traps.”

“One day they put a sticky trap right near my mom’s bathroom, near where my mom kept her personal things,” Leuvelink recounted. “So my mom went to go to the bathroom and the bottom of her pants got stuck on one of the sticky things and she couldn’t get it off. She had to cut the pants just to get the sticky thing off.”

Alvaro Vieira’s initial admission to the Gabriel House happened in a matter of days — a sign that something was off, Chris Vieira said, as the family had been on waiting lists for months.

His father was still on several waiting lists when the Gabriel House fire broke out, the son added.

“When he got there, we knew it was already going to be a little problem, because he got in so easy … they just took him in. I was like, ‘Yeah, that doesn’t sound right,’” Chris Vieira said.

From the start, Chris said the staff didn’t properly care for his father’s medical needs.

Alvaro Vieira had a stroke in his 40s that left half of his body paralyzed, and he required specific medication when he was admitted to the Gabriel House, which was to be administered under supervision.

But several weeks after his admission, Chris Vieira’s sister found stockpiles of medication in their father’s room — which showed he wasn’t taking the medication under proper supervision and was hiding it himself.

This was “a big deal” and a “serious issue,” Chris Vieira said, and though it was solved after the family spoke with facility management, the incident left them worried.

In 2023, Gabriel House and its owner, Etzkorn, were subjects of a state compliance report by the Executive Office of Elder Affairs. The report identified a number of violations by the facility, especially when it came to proper and updated documentation of resident care.

Many residents’ records lacked necessary reassessments and reviews, and documentation for the Evidence Informed Falls Prevention program was missing for all reviewed years, raising concerns about resident safety.

There were also missing documents for eye drop medications and improperly stored medications, and inconsistencies in the Gabriel House’s “correspondence log,” which helps ensure reliable, continued resident care.

Additionally, the report included 26 incident reports for resident emergencies that were filed beyond the required 24-hour reporting window, and three employees’ health records were missing.

Over the past year, the Vieira family fought hard for the stained, smelly carpet in Alvaro Vieira’s room to be replaced with wood flooring, his son said. It had only been replaced just before the fire.

The daughter of an 82-year-old resident who escaped the fire, speaking on the condition of anonymity to protect her family’s privacy, said the carpeting inside Gabriel House was “disgusting.” The building was “run down and old,” she said, but her mother settled in and made friends during the two months she lived there, several of whom died in the fire.

Alvaro Vieira, who was rescued from his bathroom window and carried from the burning building, was hospitalized but is “doing well,” his son said. He is “refusing to go back” to the Gabriel House under any circumstances.

Donna Murphy, a five-year resident, said the facility’s owner “didn’t care about people’s lives.” She wasn’t at the Gabriel House the night of the fire — she’d gone to visit family, the only night she’d been away in her entire time living there.

Murphy listed several issues she had at the facility, including exposed electrical wiring in her bathroom, which made her feel unsafe.

“I hated taking a shower,” she said. “All the wires were exposed. It was dangerous … they’re slum lords,” she said of the owner.

Is it time for new assisted living regulations, both state and federal?

Nearly 18,000 people reside in assisted living settings in Massachusetts, according to the state’s annual census for 2025. The facilities aren’t regulated like nursing homes, which are subject to both federal and state-specific standards.

Assisted living facilities exist in a gray area that allows for varying interpretations state by state, and ultimately, facility by facility.

“Assisted living is not regulated by the federal government at all, even though there is a fair amount of money going into assisted living at this point from Medicaid,” said Toby Edelman, senior policy attorney at the Center for Medicare Advocacy. “All of the regulation is at the state level. So whatever the states do is what they do.”

Edelman believes it’s time for the federal government to step in, given the rise of the assisted living industry as a growing model of desired care over the last 25-plus years.

“We’re spending a lot of Medicaid money and have no Medicaid regulations (for assisted living),” she said. “That makes no sense to me. There should be some federal standards to get the money.”

At Gabriel House, approximately 75% of residents were on MassHealth, the state’s Medicaid program.

In Massachusetts, unlike nursing homes, there are no specific staffing requirements for assisted living facilities, according to the standards outlined in state law.

Facilities must develop and implement their own process to determine staff levels, and must have “sufficient staffing at all times” for resident needs as deemed by the facility owners’ assessments on a “24-hour per day basis.”

Johnson, the current employee at Gabriel House, said it was typical for two workers to be on duty during night shifts — and sometimes, there was only one at the facility. Others corroborated that.

“They would say, ‘we just need a body,’” Johnson said, and emphasized “a body.”

• Read more: Gov. Healey unveils safety measures for assisted living facilities after Fall River fire

Massachusetts law does address the need for emergency plans at assisted living facilities, but it doesn’t include many specifics.

“An emergency preparedness plan is critical,” said Alice Bonner, senior advisor for aging at the Institute for Health Care Improvement and former state secretary of elder affairs from 2015 to 2019. “If there is no other take-home message, I would say it’s just really important people in the public know that.”

“Educating people who live and work in these environments because they should know that emergencies can happen and how they would respond,” she said.

Staffing levels and emergency preparedness plans at assisted living facilities are subject to multiple annual reviews by the Executive Office of Aging and Independence.

Lanzikos, of the Dignity Alliance, is laser-focused on turning the Gabriel House tragedy into “meaningful reform” at the state level. And he’s not alone — a chorus of state officials and senior care advocates have echoed similar sentiments over the last week.

In the days since the fire, the Dignity Alliance has already sent a letter to Attorney General Andrea J. Campbell about “the development of comprehensive assisted living regulations that bring us into the 21st century.” It also released a policy reform framework outlining the “failures exposed” by the fire and key recommendations.

On Friday, Gov. Maura Healey announced the state was taking immediate action in light of the Gabriel House fire. Starting next week, the Executive Office of Aging and Independence will launch a statewide fire and life safety initiative to ensure all 273 assisted living residences in Massachusetts are prepared to protect residents during emergencies.

Facilities will be required to submit disaster and emergency preparedness plans for state review within 30 calendar days, as well as issue a letter to residents and families outlining the plans within five business days.

“We need to make sure that the buildings, the staffing, the training and the overall administration of assisted living residences are appropriate to meet the needs of the folks who are inhabiting them today,” Lanzikos said.