One such home was St. James Place in Chester, where a resident's facial wound was allowed to fester for so long last year that emergency-room doctors removed 50 maggots from it.

Regulators closed that home in the fall. They had taken no action in response to a death there in 2004; an advocacy group in a letter to state regulators complained that the dead woman had been found "nearly naked, filthy, and lying upside-down in her bed with her head lying in a bedpan containing dried urine."

Two weeks ago, the state Attorney General's Office filed criminal neglect charges against three former St. James employees in connection with the maggots case.

James-Marie, where Johnson cooked to death on a radiator, does not have a history of serious regulatory violations.

State officials could find no records on the Johnson case.

"Without evidence and documentation, I have to assume the department did not properly investigate," Kroh said of the Johnson death.

The home's owners, Albert and Rhonda Edwards, said in an interview that the state had looked into the matter - and cleared them. They said that Johnson had been sick and unsteady on his feet, and that they had urged their staff to check on him at night.

The night he died, they believe, a staff member found the bathroom door locked and took no further action, Albert Edwards said. They called the death an unavoidable tragedy.

Owners of facilities that cater to poor people say delivering the best possible care for $1,062 per month is extremely difficult. Advocates for the poor agree that the state should contribute more.

"The problem is that we're talking about a fringe element of society. . . . They have no money. They have no status. They have no political clout," said Bob Meek, managing attorney of the Philadelphia office of the Disabilities Law Project.

"Regular middle-class people are just as happy not to know about them. They don't want to hear about it, and they certainly don't want to pay for it."

But the poor represent only about a fifth of the state's assisted-living population. The Inquirer's review also turned up problems at well-heeled suburban facilities that command $5,000 or more a month.

At some, an upscale appearance can mask weaknesses in care or supervision.

When former Main Line resident Julian Michaelson, suffering from mental illness, wandered from the Willow Lake home in Willow Grove in January 2006, "staff and managers were untrained and unable to handle emergencies" and never did a coordinated search, according to a state inspection report.

Michaelson drowned in the lake. His death was ruled a suicide.

Afterward, the state cited the home for a raft of violations, including failure to comply with rules about medication, safety, resident rights and training.

A spokesman for the Florida company that owns Willow Lake, Al McKinney, declined to comment on the case's specifics but said: "Our sympathies, of course, go out to the family of the resident. We always strive to provide a safe and healthy environment. . . . Unfortunately those things happen, and everybody feels terribly sad."

Two other high-end facilities, owned by the former Alterra Healthcare Inc., were host to some of Pennsylvania's most serious known cases of harm. Before its 2003 bankruptcy, Alterra was the nation's largest assisted-living chain.

Bucks County resident William Neff, 83, was murdered by an Alterra employee in 2000. And three residents of a State College home run by Alterra died of complications from severe bedsores in 1999 that weren't properly treated, according to court records. (The company disputed that.)