Minutes before the shooting, the administrator sent the older man's doctor a fax about the threats, saying a nurse on site felt the 87-year-old "may be homicidal."
The staff should have heeded the warnings and taken action, the state Department of Social and Health Services said in an investigation obtained by The Herald.
Last week, the state ordered Josephine Sunset Home to hire a consultant to bring its operations into line with state law. The home can't admit new residents until it fixes safety problems.
The state says the home did not have an emergency plan in place that may have prevented the shooting. Josephine also did not properly investigate the resident's claims of alleged mistreatment by the staffer who was shot, the state said.
The shooting happened Feb. 4. Resident Arthur Hames got into a confrontation with Roger Holbrook, a 59-year-old supervisor at the home, according to police reports. Hames retrieved a handgun from his apartment and shot Holbrook, who survived. Guns are not allowed at the home under Josephine policies.
Hames was not seriously injured during the confrontation, but he died of longstanding health problems a few weeks later at a local hospital. The criminal case against him was dropped after it became clear he was dying. He also had been depressed and suicidal, according to DSHS and police records.
The home received a letter March 25 outlining the alleged violations, DSHS district administrator Linda Moss said. The letter also details restrictions placed on the home's license as a result of the investigation.
"We got it wrapped up, and they need to do some work," Moss said.
Josephine's chief executive officer Terry Robertson declined to be interviewed for this story. He released a prepared statement last week.
"We just received the written report and are in the process of addressing each comment," he said. "The Josephine staff, residents and amazingly supportive Stanwood community are looking forward to quieter days."
Holbrook did not respond to a request for comment.
In keeping with the state order, he currently is not allowed on the property. Robertson declined to say whether Holbrook remains on staff.
Records show Hames had complained about Holbrook to Josephine staff multiple times over the past few months. Hames also had a history of being difficult and making angry outbursts, the state found.
Hames and Holbrook reportedly got into a struggle in September in Hames' apartment. Holbrook said Hames tried to hit him, and Holbrook grabbed Hames' wrist to stop him. Hames suffered minor wrist injuries.
In November, Hames claimed that Holbrook put his finger in Hames' ear.
The home determined that Holbrook meant the action as a joke, but that it was inappropriate and potentially offensive.
Holbrook at the time was put on 90 days probation and ordered to forfeit four days' pay. All Josephine staff also were directed not to joke with Hames because of his temperament.
Holbrook's license to work as a nurse in Washington is active with no history of disciplinary action, state Department of Health spokesman Donn Moyer said last week.
Police have never received any complaints about Holbrook, and he never was suspected of a crime in connection with the events leading up to the shooting, said Shari Ireton, spokeswoman for the Snohomish County Sheriff's Office.
The 20 pages of documents released by DSHS are silent about how Hames got a gun.
He had lived at Josephine since July. His wife lived there too.
On Feb. 4, Hames reportedly was upset with staff over an earlier disagreement. His wife had needed to be picked up from a hospital. Staff drove to pick her up, but Hames wanted to drive, the state said in its report. Hames had been ordered by his doctor not to drive for safety reasons.
Hames struggled with depression, and staff also were supposed to monitor him out of concern that he might hurt himself.
That morning, he told another nurse that he wanted to kill Holbrook, using either a gun or a car. Several staffers overheard the remark.
The nurse told a supervisor and later went off shift. Another manager also spoke with Hames about 11:30 a.m.
Holbrook sent Hames' doctor a fax about the threat between 2 p.m. and 2:30 p.m. The fax describes Hames as potentially homicidal. The shooting happened at 2:45 p.m.
Josephine must update its emergency and incident management procedures, the state said. The home also needs to review how it handles allegations of abuse.
Josephine must submit plans to correct the problems by early April. It also can request an informal dispute resolution or an administrative hearing over the state's report and enforcement plans.
Rikki King: 425-339-3449; firstname.lastname@example.org
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