FALL RIVER, Mass. (AP) — A Massachusetts assisted-living center where nine residents died in a fire was cited for failing to immediately report more than two dozen health and safety incidents, according to regulators’ most recent review of the facility.

Five men and four women were killed and at least 30 others were injured Sunday night at Gabriel House in Fall River, about 50 miles (80 kilometers) south of Boston. Some of the 70 residents were rescued by ladder after screaming for help from the windows of the three-story building. Investigators have not determined the cause of the blaze, which was the state’s deadliest fire in more than four decades.

The 100-unit facility, which opened in 1999 in a former motel built decades earlier, was last inspected by the state on Oct. 31, 2023, according to a report from the state Executive Office of Elder Affairs.

The report cited the facility for seven deficiencies, four of which were repeat problems. After the facility responded with a corrective action plan, it was re-certified through November 2025.

Most of the issues involved missing documentation. For example, seven resident files that were reviewed were missing documents to indicate that their service plans were reassessed within 30 days of moving in, as required. The plans outline the services each resident receives, including whether they need help with medication and meals.

The review also found problems with the reporting of safety incidents. Facilities are supposed to submit reports of incidents that could have a significant negative effect on residents’ health, safety or welfare within 24 hours, but the review found 26 reports that were sent later than that between May 5, 2022, and Oct. 31, 2023.

The report did not specify the total number of incidents, or provide any details about what they involved.

The state also watched two staffers provide medication assistance to seven residents and found several problems, including failure to document when eye drops were opened, loose tablets in medication storage areas and partially opened medication.

Advocates question staff size and other issues

Some residents said only two or three staffers were working at the time of the fire, and they offered little help.

“They left us alone and ran out into the parking lot,” said Lorraine Ferrara. “I was hanging out the window — ‘Help! Help!’ and they just kept running.”

Paul Lanzikos, a former Massachusetts secretary of elder affairs and co-founder of the advocacy group Dignity Alliance, said the group was concerned about reports on the lack of fire drills, the small number of staff members for a highly dependent population and safety issues such as a broken elevator and air conditioners in the windows.

“It’s a terrible tragedy that should have never happened,” Lanzikos said.

Richard Moore, another co-founder of Dignity Alliance, has asked the attorney general to investigate based on similar concerns as well as the facility owner’s history. Dennis Etzkorn, owner of Gabriel Care LLC, was indicted on medical assistance fraud and kickback charges in 2012, though the charges were dismissed three years later.

“The fact that it happened in the past and that this now happened suggests that there should be a more thorough investigation of that,” said Moore, former head of the Massachusetts Assisted Living Association and a former state senator.

He said the assisted-living industry overall needs more rigorous regulation and oversight. And while it’s too early to say what went wrong at Gabriel House, he said the staffing levels and training appear to have been inadequate.

Regulations require emergency plans

Current regulations do not require a specific number of staff members, but the rules say facilities “shall have a plan to secure staffing necessary” to respond to emergencies.

“There should have been more staff. They should have been trained in the case of fire or other emergency,” Moore said. “They should have been doing fire drills. It seemed like residents didn’t know what to do.”

Etzkorn declined to comment to The Associated Press. He told the Boston Globe in a statement Monday that he and his family were “devastated by the tragedy” and that he will continue to cooperate with authorities.

Meanwhile, a state commission working to improve long-term care in Massachusetts held a moment of silence Tuesday “for the lives that were lost and the lives that were put on the line” in Fall River.

The Assisted Living Residences Commission, created by lawmakers last year as part of a broader effort, faces an Aug. 1 deadline to recommend policies to ensure facilities meet the health and safety needs of residents. But members said they may seek more time given the fire.

“We need to do a deep dive based on the investigation results with this facility, but also the facilities like this one,” state Rep. Thomas Stanley said.

Some residents still homeless

By Tuesday morning, the facility’s broken windows had been boarded up, and bouquets of flowers and a rosary were set on the ground against a post wrapped with yellow police tape. A steady stream of cars pulled up to the Catholic Charities Diocese of Fall River to drop off donated items for the displaced residents, and the city is working with multiple organizations to collect money.

“There’s a lot of generosity and love being shared with the city of Fall River and the people who suffered so much the other night,” Fire Chief Jeffrey Bacon said.

Ann O’Neil-Souza, chief of staff for the mayor, said city officials expect to find homes for the survivors from Gabriel House by the end of Tuesday. She said most were being placed with other facilities in the city and with family, and hospitals have been asked to work with social workers to ensure patients find housing when they are discharged.

The dead ranged in age from 61 to 86, authorities said. The Bristol County District Attorney’s Office identified seven of the deceased as Rui Albernaz, 64; Ronald Codega, 61; Margaret Duddy, 69; Robert King, 78; Kim Mackin, 71; Richard Rochon, 78; and Eleanor Willett, 86. The office said the names of a 70-year-old woman and a 77-year-old man had not been released pending notification of family.

___ Ramer reported from Concord, New Hampshire. Smith reported from Providence, Rhode Island. Associated Press Writers Michael Casey in Boston and Kathy McCormack in Concord, New Hampshire, contributed to this report.