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The report adds to a list of issues raised with the Gabriel House facility over the years. A resident filed a lawsuit recently alleging the facility was not properly managed, staffed or maintained and that “emergency response procedures were not put in place.” The son of another resident said an elevator had been out for as long as nine months at one point.

The state’s deadliest blaze in more than four decades has highlighted the governing assisted-living facilities that often care for low-income or disabled residents. Gov. Maura Healey declined last week to weigh in on the efficacy of state and local inspections. Instead, Healey has touted that a state commission is currently working on recommendations to improve assisted-living facilities.

State records released Tuesday include about two dozen complaints about the facility during the last decade, including several related to “abuse, neglect or financial exploitation" but details are redacted. Other complaints involved a resident getting stuck for hours in an elevator that was then out of service for months, and staff members who threatened residents and withheld medication.

There also were complaints about a nurse withholding medication, “environmental safety” and a cook: “The cook is obsessive, controlling and abusive.”

The most detailed complaint is from 2015 and appears to have been written or dictated by a resident. It lists more than a dozen issues, including bed bugs, roaches over-medicated residents and fist fights in common areas.

“It is a place where you can’t feel safe due to other patients and corrupt staff,” the complaint states. “The staff treat the people there very cruel and show no respect for them or their needs.”

Dennis Etzkorn, the owner of Gabriel House, has said he will not speak to journalists and is focused on helping families of the victims and cooperating with the investigation into the fire.

Most recently, documents show that state officials were alarmed about the ongoing elevator issues as of spring 2025. A field supervisor with Massachusetts’s long-term care ombudsman made a plea in February to the state to investigate Gabriel House’s faulty elevator, saying that every time he made a call about the problem he was met with “excuses.”

“Please call this place and see if this is true … if so we need a remedy /plan asap,” an unnamed official wrote to the office’s assisted living certification specialist.

Etzkorn later wrote to the office detailing the timeline of the elevator problems that said work would begin in March after it was first alerted in September 2024.

Before the July 13 fire, the most recent compliance review found numerous repeat violations, many related to record keeping. After the facility submitted a corrective plan, the state renewed its certification in December 2023.

Investigators said last week that the by either someone smoking or an electrical issue with an oxygen machine. The blaze left some residents of the three-story building hanging out of windows and screaming for help.

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Associated Press Writer Kimberlee Kruesi in Providence, Rhode Island, contributed to this report.