Betty Trainer, 81 and suffering from dementia, died of heat exhaustion in 2005 after wandering off from her Bucks County care home during a fire drill. They found her body near her husband's grave.

June Loth, 74, who raised her family in Levittown, succumbed to complications from when she was raped in 2004, authorities say, by a live-in handyman in a home outside Pittsburgh.

In December, John Lambert, 95, tumbled down an unsecured basement stairwell at a sparkling Main Line complex and broke his neck. At the same home a few years before, a resident killed another resident.

Since 2000, at least 55 assisted-living residents have died across the state under circumstances that raise questions about whether they were cared for properly and whether their deaths could have been prevented, an eight-month Inquirer investigation has found.

Uncounted others were beaten or neglected at the state-regulated facilities, which are also known as personal-care homes. At least five were raped.

The Inquirer's examination of Pennsylvania's assisted-living industry - based on thousands of pages of public records and hundreds of interviews - found a long list of health and safety violations, a history of substandard care, and a system of state oversight that, until recently, often allowed deficient operators to violate safety rules with virtual impunity.

While most personal-care homes appear to provide reasonably good care, a significant segment of the industry has been so problem-ridden for so long - and the regulation of it has been so lax - that elder-care experts call it one of Harrisburg's worst failures.

"The situation with personal-care homes really is the shame of the state," said Sue Walther, executive director of the Mental Health Association of Pennsylvania and chairwoman of a state coalition of personal-home advocates.

The shameful state of assisted living in Pennsylvania has been well-chronicled for decades: in audits, in newspaper accounts, in a 2002 grand jury report after a Bucks County murder.

Yet state politicians have placed more emphasis on satisfying the concerns of the industry than on protecting vulnerable residents, The Inquirer found.

When the state set out in the late 1990s to overhaul health and safety rules for personal-care homes, lobbyists and legislators dragged out the debate for years - and significantly diluted key provisions of the original proposals, according to public records and interviews.

Top Rendell administration officials at the agency in charge of protecting assisted-living residents - the Department of Public Welfare - acknowledge that regulation was inadequate for many years, including two years under their watch.

They say they inherited a broken regulatory system when Gov. Rendell took office in January 2003 and have made substantial progress toward fixing it.

But they concede they did not begin to turn the agency around until the spring of 2005, when a new top regulator took over - Rendell's third.

"I wish I could have made more drastic change sooner," Welfare Secretary Estelle Richman said last week.

That regulator, Karen Kroh, has replaced half her staff, boosted enforcement actions by 55 percent, and revoked the licenses of 75 facilities.

But in an interview, she acknowledged that her tiny complement of inspectors - 31 for nearly 51,000 Pennsylvanians in 1,590 homes - was overwhelmed. While trying to keep up with investigating complaints, they have fallen badly behind on inspections, she said.

"This program has so many systemic problems that have gone unnoticed, unchecked and unregulated for a decade," Kroh said. "I don't have enough staff to fix it.

"By the time we get out to them, many homes are in so much trouble that they can't fix the problems - or somebody's already been harmed."