25 Investigates: Few surprise state inspections at assisted living residences, state records show

How often are state inspectors inside the 273 assisted living facilities in Massachusetts?

That’s a big question we had after the tragic fire in Fall River that claimed the lives of 10 people.

25 Investigates spent months working to obtain public records. We found surprise inspections — stemming from complaints or accidents — happen an average of about once (1.32) a month when examining records from the beginning of 2023 through August of 2025. Advocates for the aging population fear there are major gaps in oversight.

On July 13, a devastating fire tore through the Gabriel House Assisted Living Facility in Fall River, exposing serious safety concerns.

25 Investigates shared exclusive images from inside the building, revealing recalled and faulty sprinkler heads still in use.

“Oh my God, the smoke came so fast. So fast,” said survivor Michael Pimental, still reeling from both the tragedy and the revelations that followed.

“Our safety is involved, and these people swore an oath basically to take care of us,” Pimental said.

In the days after the tragedy, Governor Maura Healey and state leaders announced new safety measures. They required assisted living facilities to send letters to residents and families outlining safety protocols and evacuation plans, and to complete mandatory safety assessment surveys. The state has since reported all 273 assisted living facilities in Massachusetts returned the survey.

During a July press conference, Robin Lipson, Secretary of the Executive Office of Aging & Independence, explained the state’s inspection process.

“At a minimum, our team that certifies these residences do a visit, a very in-depth visit, with a full day or two of preparation before an actual site visit,” Lipson said. “They do that at least every two years. But we have the authority to go out unannounced and more frequently than that…and we do. So just know that that’s baseline.”

But 25 Investigates wanted to know more about that baseline.

Through a public records request, we obtained data on unannounced inspections conducted in response to complaints or concerns between January 2022 and August 2025.

Unannounced Spot Inspections at MA Assisted Living Residences (ALRs)

2022: 0

2023: 19

2024: 16

2025 (through August): 6

Source: Massachusetts Executive Office of Aging & Independence

There were no surprise inspections in 2022, which the state attributed to a COVID-related backlog of routine inspections. In 2023 there were 19, 16 in 2024, and just six through August of this year — averaging just over one (1.32) per month statewide since 2023.

“When you look at the records, we got back from the state identifying their unannounced spot inspections, what do they say to you?” 25 Investigates asked Paul Lanzikos of Dignity Alliance Massachusetts, an organization that advocates for seniors and people with disabilities.

“The state needs to ramp up their efforts,” Lanzikos said. He called the current oversight “limited, lax, not sufficient.”

Dignity Alliance acknowledged while many complaints in assisted living communities go unreported, the group expressed concern that the state was only going into homes for surprise visits based on a complaint or major incident, calling the process reactive.

“Meaningful change needs to happen now,” he added. “You can’t wait because we have thousands of people in vulnerable situations.”

Dignity Alliance is pushing for regulation updates that would include more frequent compliance inspections-annually instead of bi-annually, more review of financial operations, and the licensure of individuals who operate assisted living residences.

“We don’t have adequate transparency. And we don’t have adequate staffing,” said State Senator Patricia Jehlen, chair of the Joint Committee on Aging & Independence said of the Office of Aging and Independence.

Jehlen said the Office of Aging & Independence is in the process of writing new state regulations— a process that began before the Fall River fire but will likely be shaped by it. There’s also an ongoing commission working to recommend policy chance, which extended it’s working timeline to the end of the year after the Fall River tragedy.

“Terrible that it took a tragedy to get us to pay attention,” Jehlen said. “But that’s brought into the open a whole lot of issues.”

Secretary Lipson declined 25 Investigates’ multiple requests for an on-camera interview.

In a written statement, her office said the state has taken proactive steps to strengthen oversight and accountability, including conducting routine compliance checks without prior notification since 2024.

“The safety and well-being of assisted living residents remain our top priority. Immediately following the fire at Gabriel House, the Healey-Driscoll Administration launched a statewide Fire and Life Safety Initiative to ensure all 273 assisted living residences in Massachusetts are prepared to protect residents during emergencies.

Through this initiative, the state took proactive steps to strengthen oversight and accountability—including requiring all residences to communicate fire safety protocols to residents and families, complete a comprehensive fire safety self-assessment survey, and submit updated emergency preparedness plans. These measures received a 100% response rate and built on our ongoing commitment to transparency, partnership, and resident safety.

To further enhance coordination between state and local partners, AGE is introducing a new Compliance Verification Form that each ALR will be required to complete. The ALR will be responsible for securing annual sign-off from its municipal fire department, and AGE will review the form during certification and recertification visits to ensure continued compliance and strong collaboration with local fire officials. We are grateful to our partners at the Executive Office of Public Safety and Security for their collaboration in advancing this important work.

The Assisted Living Residence Commission continues to examine additional policy and regulatory measures to further strengthen resident safety, and the Healey-Driscoll Administration remains fully committed to ensuring Massachusetts’ assisted living communities are safe, supportive environments for aging residents.” -- Sec. Robin Lipson, Executive Office of Aging & Independence

“Everybody who lives in Massachusetts deserves to live in safety,” Lanzikos said. “And that includes people who are frail and have a lot of support needs.”

The Office of Aging and Independence says as of 2024 all routine compliance checks became unannounced visits.

The state conducted 131 routine, unannounced checks in 2024, and 114 so far in 2025 — but according to state records, none of those were at the Gabriel House.

The Fall River residence would have been up for recertification in November. The state last recertified it in December 2023. During it’s last onsite visit October 31^st, 2023, the state found the Gabriel House was not in compliance with state regulations including missing employee medical records, issues with the handling of residents’ medications, and delayed reporting of resident incident reports. The state reports corrective action was taken.

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