The department's record-keeping has been so poor that Kroh is unable to say how many people died of unnatural causes in the homes before 2005. Nor is she able to say how many homes were cited with serious safety violations before that year.

Using documents from the welfare department, the courts, and the Philadelphia medical examiner, The Inquirer identified 55 deaths in the last seven years that pointed to possible failures in care and supervision at assisted-living homes.

In many death cases before 2005, the welfare department did not investigate or took little meaningful action. Since Kroh took over, homes have been sanctioned - and some closed - after deaths linked to inadequate care.

The Inquirer's review of welfare department records involving more than 80 facilities, dating back to 2000, found missing documents, superficial investigations, and a tolerance for repeated violations. For example:

At the James-Marie Personal Care Home in Germantown, Elmo Johnson, 75, was found slumped over a radiator with third-degree burns in 2003. He had been there for four hours, according to a medical examiner's report, which said Johnson had died of "thermal injury." The state cannot find any record that the death was investigated. The owners say they did nothing improper, and say a state inspector cleared them - after telling them to get better radiator covers.

At Hill House Manor in Bensalem - part of the Independence Blue Cross subsidiary NewSeasons - six people had wandered away before Trainer's death in 2005, police records show. The facility - sanctioned for "gross incompetence" after her death - had previously been cited for failing to properly supervise residents with dementia. A lawyer for the home said it was not at fault in Trainer's death, and disputed the notion that Hill House residents were not well-supervised.

At Arden Courts in suburban Pittsburgh, an employee was charged with raping an 84-year-old Alzheimer's patient in 2005 - three years after a resident with a history of violent behavior beat another resident to death. Regulators, who repeatedly found that the home had insufficient staff, took no action after the rape and, in a settlement, collected a $780 fine after the killing. Officials from Arden Courts, part of the national HCR ManorCare chain, said in a statement that they had acted appropriately and had substantially improved operations since 2002.

At Country Living Personal Care outside Scranton, regulators did nothing after learning that the home admitted a convicted sex offender who later raped an 84-year-old resident in 2002. The owner, who acknowledged mistakes during court testimony, declined to comment and hung up on a reporter.

All of the homes are still open, though Hill House has been sold.

Noting that those cases had happened before she took over, Kroh said she could not defend the department's past actions. Investigations often had been inadequate, she said.

"I think we've started to fix the program, but there's still a lot to do," she said.

Kroh said record-keeping and the quality of investigations in the Philadelphia region had been particularly poor.

"We found all kinds of things stuffed in the wrong files," she said. "I suspect there were also many deaths that were not properly investigated and cited."

Asked why she hadn't moved to fix such basic failings when she took office in early 2003, Richman said she had been busy with other pressing priorities in her sprawling multibillion-dollar agency.

"People were dying there, but people were dying in a lot of places," she said in an interview last week.

Richman promised to add more assisted-living inspectors.

Rendell declined to be interviewed about personal-care homes. Asked about his record during a public appearance last week, he said:

"We moved faster than any other administration in the history of Pennsylvania, and we put more money into dealing with that than any administration in history."

A Rendell spokeswoman later added: "The problems with licensing and enforcement of personal-care homes go back over 20 years," and Rendell has made "steady progress" in fixing them.