Illinois Gov. Bruce Rauner’s administration knew the Quincy veterans’ home had bungled a water-system repair in violation of state health codes but chose not to cite the facility for a mistake that likely contributed to a fatal Legionnaires’ outbreak in 2015, state records show.

That information was included in one of more than 132,700 pages of documents the Rauner administration released to WBEZ Friday afternoon, less than four days before the governor faces re-election. The avalanche of records relates to repeated Legionnaires’ outbreaks at the state-run home, an issue that has dogged Rauner’s re-election battle against Democrat JB Pritzker.

One email has Rauner’s public health director explaining how a bacteria-laden “broth of legionella” was mistakenly released into the Illinois Veterans Home water system before a 2015 outbreak killed 12 residents.

That discharge had been previously highlighted in state and federal reports. But until now, it had not been known the release was serious enough to be a “citable offense” under state rules — an important detail that could weaken the state’s position in a dozen negligence lawsuits brought by victims’ families.

Despite spending millions of dollars in water-system upgrades since the initial outbreak, the state has struggled to stop residents and staff at the facility from being sickened and dying from Legionnaires’. Between 2015 and last February, 14 deaths have been linked to Legionnaires’ at the home, and nearly 70 people have contracted the sometimes-fatal form of pneumonia.

WBEZ began requesting documents relating to its investigation of the outbreaks from Rauner’s administration more than a year ago. His office has been handing over heavily censored documents in batches over the last several months. But while Friday’s release was largely readable, it was nearly twice as big as any previous production, making it impossible to peruse thoroughly before Tuesday’s gubernatorial vote.

Rauner’s office did not address questions about the timing of the documents’ release so close to the election. But a top aide suggested it underscores the Rauner administration’s commitment to transparency and its spirit of cooperation toward state lawmakers and Auditor General Frank Mautino, whose office has its own Quincy inquiry underway.

“We have provided hundreds of thousands of pages of documents, participated in dozens of hours of public testimony at the General Assembly and cooperated with the auditor general in his review,” Rauner spokeswoman Elizabeth Tomev said in an email.

‘Broth of legionella,’ but no state citation

By Aug. 29, 2015, the Quincy veterans’ home had been in the throes of its first fatal Legionnaires’ outbreak for more than a week. Five residents had already died.

In the newly released document from that day, state Public Health Director Nirav Shah had a phone conversation with an engineer in his agency about the mistaken release of as much as 1,600 gallons of stagnant water into the veterans’ home water supply more than three weeks earlier. After the call, Shah wrote an email summarizing the conversation to the head of his agency’s communications office.

Shah outlined how a malfunctioning tank used to supply the home with hot water sat dormant for more than a month, filled with water that had cooled to 80 or 90 degrees — a level he described as the “optimal growing temperature” for Legionella, the bacteria that causes Legionnaires’.

When the tank was repaired on Aug. 6, 2015 and put back online, the facility failed to empty out the stagnant water, which wound up being warmed to a temperature in which Legionella can still flourish. Gallons upon gallons of that water were then distributed “for normal use throughout the facility,” Shah wrote.

He likened it all to a “broth of legionella” and said it likely contaminated shower heads in the home within a week of the repair.

“This is a citable offense,” Shah wrote, saying the action “created a condition that would have affected quality (sic) of potable” water in the home.

“If we had wanted to cite them, we could have done so,” he continued. “It’s a standard, not a rule.”

The first confirmed Legionnaires’ fatality at the home was veteran John Karlicheck, who began showing symptoms on Aug. 20, two weeks after the repair, according to his family’s negligence lawsuit. By Aug. 21, the facility had two confirmed cases and knew it had an outbreak on its hands. Karlicheck died Aug. 22.

The malfunctioning tank was alluded to by the federal Centers for Disease Control and Prevention in a December 2015 assessment of the first outbreak. The tank also rated a mention in a April 2018 report by Shah’s agency to the General Assembly. Neither report characterized the contamination breach as a possible violation of state law.

Late Friday, a Shah spokeswoman said the Illinois Department of Public Health wasn’t on the scene when the tanks were repaired, though they disclosed the situation to the CDC when they learned of it later. But she disputed the certainty that water from the malfunctioning water tank truly amounted to Legionella “broth” because the stagnant water that poured through the home’s shower heads and sink spigots was not tested before its release.

“The water in the boiler had already been released so there was no remaining water that IDPH could test to confirm Legionella,” said state Public Health spokeswoman Melaney Arnold. “However, for IDPH, this information was a turning point that prompted us to focus our investigation on the potable water system.”

Arnold said the veterans’ home “could possibly” have violated a section of Illinois Administrative Code dealing with plumbing safety. But she said her agency did not issue any citations against the facility because the only result of any sanction would be an order to correct the problem, which Rauner’s administration thought it had done through a series of safety measures.

“At that time, the home had stopped using hot water and was on water restrictions so the problem had been corrected,” Arnold said. “Additionally, IDPH was not there when the situation occurred and did not witness what had happened.”

Expert: Lack of enforcement ‘doesn’t really make sense’

Even though Rauner’s administration chose not to cite its own Department of Veterans’ Affairs for the plumbing mistake, there were pre-existing state laws and regulations that seem designed to prevent just such a situation.

State rules require the Public Health Department to ensure that state veterans’ homes maintain water systems that are in “safe, clean and functioning condition.”

Under state law, Illinois’ Nursing Home Care Act authorizes the state public health director to cite the Illinois Department of Veterans’ Affairs for any instance that “creates a substantial probability” for “the risk of death or serious mental or physical harm” to veterans’ home residents.

One nationally recognized infectious-disease expert said he was confounded at the state’s reluctance to sanction the Illinois Department of Veterans’ Affairs when the alleged violation jeopardized the safety of the home’s water supply.

“When you’re talking about public safety and measures that are clearly trying to minimize people’s exposure to incontrovertibly dangerous environments, discretionary enforcement doesn’t really make sense to me,” said Amesh Adalja, senior scholar at the Johns Hopkins University Center for Health Security in Baltimore.

A Quincy-based lawyer representing three families who lost loved ones in 2015 went farther, blasting Rauner’s administration for recognizing the wrongful release of contaminated water in the home warranted some form of sanction, yet failing to act on it.

“I hate to use the word, ‘cover-up,’ because I think it’s a fairly pointed word, but it sure seems like another example of them…knowing they didn’t do something correctly and just continuing with this line in the sand of ‘we did nothing wrong,’” attorney Ryan Schuenke told WBEZ.

Illinois Attorney General Lisa Madigan’s office announced a criminal probe into the Quincy outbreaks on Oct. 3. A spokeswoman declined to comment on Shah’s email outlining the decision not to cite the home.

Shah has fended off legislative calls for his resignation. That’s even though he played a role — along with Rauner’s press office and the former head of Veterans’ Affairs, Erica Jeffries — in a crucial, six-day delay in notifying residents, their families and the public about the presence of Legionnaires’ at the facility in 2015.

Madigan’s office, which appeared before a grand jury in Quincy on Oct. 25 as part of its Legionnaires’ investigation, has indicated one focus is on whether the Rauner administration properly notified the public about multiple Legionnaires’ outbreaks at the home.

On Friday, Shah’s spokeswoman said Shah does not consider himself to be a target of the probe, though she declined to answer whether he has retained the services of a defense lawyer.

“He has no reason to believe that he is the focus of the investigation, and he will cooperate fully if requested,” Arnold said. “Because it’s a pending inquiry, we cannot comment further.”

Dave McKinney and Tony Arnold cover Illinois state government and politics for WBEZ. Follow them @davemckinney and @tonyjarnold.