Last year, as Eleanor Willett and her family searched for an assisted living facility, the dollar signs staring back at them were "outrageous."
But emerging as a rare option -- and in some ways a last resort -- was Gabriel House, a former motel-turned-assisted living home in Fall River located about a 15-minute walk from where Willett's daughter, Terry Leuvelink, lived.
Its residents were primarily low- and middle-income people who couldn't afford private-pay facilities -- approximately 75% of them were on the state's Medicaid program, MassHealth.
During their first walkthrough, Gabriel House was "not impressive at all," Leuvelink said, describing it as "shabby." But she encouraged Willett to stay positive -- they'd be living close to each other, and it wasn't a nursing home, something they were trying to avoid.
"It's affordable," Leuvelink recalled thinking. "It's a roof over your head. That's what (my mom) said, too. 'That's all I need. A roof over my head, some place to lay my head down.'"
Willett and her family were pleasantly surprised to find her room had been painted and the flooring replaced before she moved in last July. They hung curtains and set up cabinets to store Willett's medication and food.
Her monthly cost at Gabriel House -- $2,400 -- left just enough money for the 86-year-old to still play slot machines at a nearby casino, something that was important to her in terms of maintaining a sense of freedom.
On July 13, Willett died in a fire that consumed Gabriel House and killed nine other residents.
The subsidized affordable care model Gabriel House operated under has drawn scrutiny from senior care advocates and state lawmakers since the deadly blaze. Many contend it isn't sustainable for facility upkeep and resident care, even though the model provides a place to go for many people who couldn't otherwise afford assisted living.
A new spotlight has emerged on the affordable facilities, as lawmakers and state officials seek potential solutions to remedy inequities and ensure safety.
There has been a laundry list of issues at Gabriel House over the years, according to state and city records. Residents and family members detailed rodents, cockroaches, indoor smoking, lackadaisical emergency planning -- if any -- and an elevator that didn't work for months at a time, stranding residents with mobility challenges on the third floor.
The facility was tired. Dirty carpets, ripped furniture and exposed electrical wiring were also recounted by residents and family during interviews with MassLive. At least three lawsuits have been filed since the July fire, all describing similar conditions and management issues.
Gabriel House epitomized a so-called affordable assisted living facility, loosely defined as a place that relies heavily on public health care or housing subsidies to stay in operation. By contrast, private-pay facilities charge thousands of dollars more per month to generate revenue, not just make ends meet.
"In my experience, I haven't seen an entity with that high level of dependency (on public subsidy)," said Paul Lanzikos, co-founder of the Dignity Alliance of Massachusetts and a former state secretary of elder affairs under Gov. Michael Dukakis. "That definitely affects the economics of running the operation. The funding is not going to be sufficient to properly maintain the building, to provide the adequate services and staffing. And I think that's been borne out by what happened at the Gabriel House."
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, room and board for a studio room cost between $1,850 and $2,400 a month, which most residents paid with their Social Security checks.
The majority of residents at the facility -- more than 80%, based on 2023 state data -- had their personal care paid for by two MassHealth-funded programs based on clinical criteria and income: Group Adult Foster Care (GAFC) or Senior Care Options (SCO).
In 2023, Gabriel House ranked among the top 10 assisted living facilities in the state with the highest percentages of traditional residents -- those not needing memory care -- on public subsidies.
And out of the more than 270 assisted living facilities in the state, there aren't many accepting subsidies to begin with. An estimated 90% of assisted living residents in the state pay privately, according to the Massachusetts Assisted Living Association, the state's industry group.
That number shows just how few assisted living options exist for low- and middle-income people, particularly at a time when the country's wealth gap is widening and people generally are living longer.
Bill Henning, executive director of the Boston Center for Independent Living, described subsidized versus private pay assisted living as a "bifurcated, two-tiered system."
People without economic resources and social capital become vulnerable, Henning said, and often end up in under-budgeted facilities.
"MassHealth rate reimbursements aren't good enough to support a higher level of care," he said.
The Group Adult Foster Care payment, for example, is $50 per day.
The Boston Globe recently reported that Gabriel House had stopped putting butter on toast in the mornings for breakfast, in what residents assumed to be a cost-saving decision. The facility was "saving every penny to the end," one resident told the Globe.
"Usually, what happens at these places is they try to keep the operation and basic services as low-cost as possible," Lanzikos said.
In 2023, Neville Place in Cambridge, also considered an affordable assisted living option, needed a new roof, heating and air conditioning system and other repairs, but lacked the money to pay for it. Ultimately, the city of Cambridge's Affordable Housing Trust gave Neville Place a $5.7 million loan.
It's another example of a heavily subsidized facility struggling with building maintenance.
Dennis Etzkorn, owner of the Gabriel House, was previously indicted for Medicaid fraud. According to court records, the 2012 charges alleged he collected more than $2 million in improper Medicaid payments by paying providers to refer potential MassHealth clients to Gabriel Care LLC, the company that owns Gabriel House.
The charges were ultimately dropped and the case was settled for $950,000 after Massachusetts Superior Court judges ruled prosecutors had improperly obtained some financial records in the case.
Etzkorn has not returned any of MassLive's requests for comment since the fire, often hanging up on reporters when reached by phone. Through a spokesperson, he has said he won't be speaking to journalists while the investigation is ongoing and he focuses on assisting displaced residents and their families.
In one statement released by a spokesperson on July 21, Etzkorn said Gabriel House "takes pride in knowing that we make assisted living possible for many community members in need who might not otherwise be able to obtain that assistance."
He called Gabriel House a "fixture in the community for decades" that is "deeply dedicated to improving the lives of our residents every day."
There are more than 17,800 people residing in assisted living settings across Massachusetts, according to the state's 2025 industry census.
The census noted most assisted living facilities in the state don't have residents participating in any public subsidy programs, again demonstrating the few that offer an affordable model.
In fiscal year 2024, 277 MassHealth members residing in assisted living participated in the Group Adult Foster Care program, according to state data.
Other public subsidy programs serving people in assisted living in the state include Senior Care Options (SCO) and Program of All-Inclusive Care of the Elderly (PACE), which are funded by MassHealth and federal dollars. According to the state census -- reflecting the 2024 calendar year -- 173 assisted living residents participated in SCO and 1,221 in PACE.
Section 8 vouchers helped pay the monthly rent for 277 assisted living residents.
The daughter of an 82-year-old Gabriel House resident who escaped the fire, speaking on the condition of anonymity to protect her family's privacy, said her mother was successful and had worked her whole life. But most assisted living facilities "wanted to take every single penny she had."
She earned too much to be covered by Medicaid but not enough to afford the next tier up of assisted living.
The rates at Gabriel House allowed the woman's mother to have some money left over each month. It wasn't picturesque, but they viewed it as "three meals a day and people there to help."
A study by the Joint Center for Housing Studies of Harvard University found, in 2023, that just 13% of adults age 75 or older who live alone can afford an assisted living facility in their area.
The study specified the city of Springfield as an example, where assisted living can be afforded by fewer than 7% of adults 75 and older.
"In the United States right now, there are very few assisted living residences that cater to or will take people with limited incomes," 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 people are willing to spend down to the point where they qualify to be on Medicaid, then Medicaid will pay the daily rate for them to live in a nursing home," she said.
Gabriel House is not alone in its model to accept public subsidies -- more than 90 other assisted living residences in the state do so as well. Although the numbers at each facility can range from one resident to over 100, who receive subsidies.
But what can't be lost in the ensuing conversation after the fire, according to Marc Cohen, is why 10 people died at the Fall River facility and not elsewhere.
Cohen is the co-founder of long-term care research and risk management company LifePlans Inc., and co-directs the LeadingAge LTSS Center at the University of Massachusetts Boston. After a tragedy, he said, it's easy to place blame on one issue. But in this instance, focusing solely on Gabriel House's affordable status risks "overlooking opportunities for making a difference that don't necessarily cost an arm and a leg."
Just because an assisted living facility accepts public subsidies "doesn't necessarily mean the facility is unsafe," Cohen said.
"There are many management actions that could be taken to mitigate problems," he said. "It's not exclusively a payment issue, and I want to be really clear about that. That can contribute to inadequate investments, but there are a host of issues. And in particular, assisted living doesn't have the same level of regulatory oversight as hospitals and even nursing homes."
There is no federal oversight for assisted living homes, creating a patchwork state-by-state approach to regulations. In Massachusetts, there are no specific staffing requirements for assisted living, and while emergency planning is required, the standards aren't specific.
Gov. Maura Healey addressed the latter immediately following the Gabriel House fire, announcing on July 18 that the Executive Office of Aging and Independence was launching a statewide fire and life safety initiative to ensure all 273 assisted living residences in the state are prepared to protect residents during emergencies.
At Gabriel House, residents and employees who spoke to MassLive said they didn't recall doing fire drills or being informed of any evacuation plans. Signs posted to the back of residents' doors told them to stay put, close the door if there was a fire and wait for a staff member.
On the night of July 13, no one came to get them -- until it was ultimately too late for 10 residents.
Also emerging in the aftermath of the fire are questions about the facility's sprinkler system and whether it was working that night. One of the lawsuits filed against Gabriel House by three residents claims the sprinklers "failed to operate reasonably" when the fire struck the facility.
Etzhorn, the owner, has said the sprinklers were tested by an unidentified third-party vendor on July 8, just days before the fire, and "found to be in working order."
The new regulations introduced by Healey last month required facilities to submit site-specific disaster and emergency preparedness plans to the state within 30 calendar days, as well as issue a letter to residents and families outlining the plans within five business days.
The state's Assisted Living Residences Commission, created by reformative long-term care legislation signed into law last year, hopes to further improve regulations. The commission voted to extend its mandate at least three months to incorporate more recommendations related to Gabriel House into its final report.
But even before the fire, the commission had already drafted recommendations related to expanding affordable assisted living options. They include:
Some commission members have also discussed the possibility of creating a task force specific to examining the subsidized affordable assisted living model.
Beacon Hill is also paying attention. Specific to the affordability conversation is a Legislature-approved actuarial study -- led by Sen. Pat Jehlen, D-Second Middlesex, and Rep. Thomas Stanley, D-9th Middlesex -- that will explore the potential for a new social insurance program for long-term services and supports.
Essentially, workers would opt in to a payroll deduction program to ultimately have more care options in their later years. It's a model that's been done in Washington State -- the WA Cares Fund is a state-run long-term care insurance program.
"If you had a dedicated program of public insurance, it would do a number of things," Cohen explained. "Everyone would share in the success or failure of that program, a built-in political constituency just like Social Security. And when people have long-term care needs, they will actually have the resources to pay for the need. You will have a major infusion of new dollars to support long-term care infrastructure."
In an interview, Stanley called the aging population combined with increasing unaffordability across the board "an emergency situation."
"People aren't prepared for their later years," he said, "for their health needs or housing needs.