Surviving War, But Not The Veterans' Home

Gerald Kuhn spent part of his service in World War II digging into French soil and exhuming the bodies of his fellow American soldiers.

It was his job in the Army to collect their dog tags and personal belongings and ship them back home to their families in the United States. It was grim work — in later years, he shied away from talking about it to his children — but he was proud of his military service.

And so when the time came, he looked forward to moving to the Illinois Veterans Home, a state-run facility near the Mississippi River, about five hours southwest of Chicago.

“He was proud to be a veteran,” said Jana Casper, one of his daughters. “He earned that right to be able to go to live there.”

But in 2015, her father was one of 12 residents to die in an outbreak of Legionnaires’ disease at the home. That disease came back in 2016 and sickened five more people. And it came back again this past fall, sickening three and contributing to the death of another veteran.

“When’s it going to stop?” Casper said in an interview with WBEZ. “How many more people are going to have to die before they can get to the bottom of what’s causing it?”

In three straight years, legionellosis killed 13 people and sickened at least 61 residents and staff at the downstate veterans’ home, and the state has failed to stop the outbreaks and other cases despite investing millions of taxpayer dollars.

The tragic and continuing ordeal at the 210-acre facility in Quincy has heightened scrutiny over how well Gov. Bruce Rauner’s administration has managed a deadly public health crisis that started after he took office.

A WBEZ investigation is spotlighting how veterans who endured unspeakable experiences on the battlefield died at the facility after being sickened by bacteria-contaminated water. Their families contend they weren’t diagnosed nor given antibiotics quickly enough to fend off what typically is a treatable form of waterborne pneumonia.

And now, Illinois’ senior U.S. senator, Dick Durbin, is saying the facility should be shuttered until its water system is fully safe. And he said it’s a “scandal” and an “insult” to veterans that the state hasn’t been able to rid the facility’s water system of Legionella bacteria over the course of nearly 30 months.

Eleven families are suing the state for negligence. But because those deaths occurred in a state facility, Illinois law caps any potential awards at $100,000 — well below the seven-figure outcomes Legionnaires’ cases have yielded in litigation elsewhere.

In 2015, a dozen residents at the home died in the first outbreak of Legionnaires’ disease, which can be contracted when people inhale infected water vapor through showers, sinks, and fountains. Legionellosis is a term that encompasses both Legionnaires' disease and a less-deadly infection known as Pontiac fever. Since the initial outbreak, the state has imposed new treatment protocols and spent nearly $6.4 million on emergency upgrades to the complex’s water treatment system.

Despite having plumbing more than a century old, those upgrades have left the Quincy home with “the cleanest water in the state,” the head of the Illinois Department of Veterans’ Affairs said recently.

But in 2016, five more people at the home contracted Legionnaires’ disease, though no one died. That’s when Rauner traveled to the veterans’ home and told reporters the state was closely monitoring the home’s water for the bacteria.

“We’re really on top of the situation,” he said at the time.

While the Centers for Disease Control and Prevention praised the state’s action plan in a report this year, it nonetheless found that the facility’s plumbing system still poses a “potential risk” for the disease, and given the facility’s old age, it declared that “completely eradicating Legionella is very challenging.”

Since that statement and the strong words last year from Rauner, three more cases hit the home this fall, resulting in the 13th Legionella-related death there: Roy Dehn, an 88-year-old Korean War veteran who was a longtime Chicago Tribune employee from west suburban Lisle. (The state disputes that Legionella caused Dehn’s death, but the local coroner determined it was a contributing factor.)

Speaking out now for the first time, families of the dead residents tell WBEZ they are looking for answers in a string of deaths they contend were wholly preventable.

Some of those family members also believe they are owed a greater apology than what they’ve gotten from the state so far, perhaps even an acknowledgement from the governor himself.

“Why didn’t he come and pay respects to the families that lost their families?” asked Diane McHatton, whose otherwise healthy 94-year-old father was among those to contract Legionnaires’ and die in 2015.

“We love this country. We raise the flag. We kneel down to pray. They can’t even say, ‘I’m sorry for your loss’? Don’t you think they should’ve? And I’m asking why? That’s what I want to know. Why?” she said. “That hurts.”

McHatton’s father is Melvin Tucker, a decorated U.S. Army Air Corps tailgunner whose B-17 bomber was shot down over Nazi Germany in 1944. Everyone else aboard died, but Tucker successfully parachuted from the burning plane as it headed toward the ground. After landing in a spray of gunfire, he was captured by a Nazi soldier and held for 13 grueling months in one of Germany’s most notorious prison camps.

"I didn't want to talk about the horrors I witnessed during the war or the nightmares that still haunted my dreams,” Tucker wrote in a 2007 memoir he published about his war experience. “But I felt compelled to do so because many people were saying that they didn't believe the stories about the atrocities the Germans committed against the Jews. I had seen them with my own eyes."

When he developed a fever at the home on Aug. 21, 2015, he was given Tylenol, according to the family. By that point, there had been five earlier confirmed cases of Legionnaires’ disease at the facility dating back to July 24 of that year, according to the CDC.

It was a detail Tucker’s family did not know at the time because the state hadn’t yet publicized the spate of illnesses.

Six days later, Tucker was still not on any kind of antibiotic and hadn’t been tested for Legionnaires’, according to his family and their lawsuit with the Illinois Court of Claims. Tucker even asked for a priest because he was “fearful he was going to die,” according to a court filing. Only then did the veterans’ home staff take a urine sample that confirmed he, too, had contracted Legionnaires’.

A day later, Tucker became unresponsive.

“That’s the hardest thing to see your daddy [like that] after all he’s gone through,” McHatton said, her voice rising and tears welling in her eyes. “For three days, he’s gasping for breath, and we couldn’t do a damn thing about it. Not a thing.”

Ten days after first getting sick, Tucker was dead.

Now, his family’s anger at state officials — about what their father went through and the continuing string of legionellosis cases — is still raw.

“What would they want done?” McHatton said. “If their dad got shot down over enemy lines, if their dad went 13 months being kicked and starved and beaten, come home, picked himself up, worked his butt off till he retired, and then have something like this happen?

“Ask them how they would feel. What would they want? We seen our dad suffer.”

As of Tuesday evening, Rauner’s office had not made the governor available for an interview with WBEZ. But Illinois Department of Veterans’ Affairs Director Erica Jeffries defended the administration’s response to the illnesses and said that veterans like Tucker got the best care possible while they were residents at Quincy.

“He was treated and cared for and loved at our home. All of our residents are, and I ask you to find a family member who says that they are not,” she said. “He succumbed to Legionnaires’ disease. It can kill you.

“We maintain and say that our homes are a place where our veterans come to live, not where they come to die.”

The state contemplated moving residents after the 2015 outbreak but decided not to, citing the strain that it could pose to frail residents in the facility’s care. The department is not currently considering plans to move residents, Jeffries said.

Her agency, which oversees all four of Illinois’ veterans’ homes, has acted on recommendations from the CDC with a series of infrastructure upgrades and protocol changes at Quincy since the Legionnaires’ outbreaks in 2015 and 2016.

Jeffries said employees at the home have been trained to better identify and respond to symptoms of pneumonia. Urine testing for Legionnaires’ and chest X-rays are now an automatic response when a patient begins showing symptoms. Health care workers at the home also get patients on antibiotics right away, even before the test results come back.

None of those protocols existed before the first outbreak in 2015 — a fact that’s evident in the negligence cases now before the state’s court of claims.

Jeffries maintained the state is doing all it reasonably can do to tamp down illnesses caused by a pervasive bacteria.

“What we have not done is remove all the piping and start again,” Jeffries said, referring to the facility’s aging plumbing system. “Short of doing that, we’ve done everything we possibly could do to ensure the safety of our residents and staff, and we’ve done everything that the CDC has recommended that we do.”

Jeffries said original plumbing at the nearly 132-year-old facility is “miles and miles and miles and miles long.” She said she didn’t know how much it could cost to replace, but ballparked it could be north of $500 million.

It is that network of galvanized piping — often more than a century old — that contains “extensive sedimentation and biofilm” and appears to “be associated with persistent positive Legionella culture results from point-of-use fixtures,” the CDC said in a June analysis of last year’s outbreak.

The agency described how testing showed those who were sickened in 2016 may have been exposed to the bacteria through a kitchen sprayer, a therapy tub, and, ominously, in-room sinks — all after the state had undertaken what the federal agency lauded as “significant remediation efforts.”

“In spite of the progress, the potable water system continued to pose a potential risk for Legionella growth and transmission,” the report said.

Jeffries said no water-use restrictions currently are in place at the complex, other than a prohibition on using jet sprays in whirlpools.

But Sen. Durbin tells WBEZ far more dramatic steps are necessary in light of the most recent legionellosis cases in October and November.

He said the state must move the Quincy home’s nearly 400 veterans and their spouses to a safe place until its century-old plumbing system is fully free of the waterborne bacteria that killed residents. If that isn’t possible, the state should build a new home, Durbin said.

“This has progressed from a disastrous situation, where veterans of the state of Illinois have lost their lives because of contamination in the water supply at the veterans’ home in Quincy, to a scandal. I just don’t think there’s any other word to describe it,” he said.

“I want an admission by the governor that we have failed these veterans, and we need to do something immediately on an emergency basis to protect those who are there to make sure this never happens again and, if necessary, to replace this facility,” said Durbin, who along with fellow Democratic U.S. Sen. Tammy Duckworth, has endorsed candidate J.B. Pritzker to be their party’s nominee to challenge Rauner as the potential GOP candidate in the 2018 gubernatorial election.

“What we have now lurching from year to year is a situation that’s embarrassing, and it’s an insult to these veterans and their families,” Durbin said.

One nationally recognized research pioneer in Legionnaires’ disease said it is not uncommon to find the bacteria in about 50 percent of all large buildings.

Janet Stout, a microbiologist who runs a Pittsburgh laboratory that specializes in Legionella remediation, said the bacteria can be controlled effectively by disinfecting the water system, and she said most long-term care facilities aren't as vigilant as the Quincy veterans’ home when it comes to testing for the bacteria. She said she is unaware of anyone ever vacating or demolishing a building because of an inability to eradicate Legionella from drinking water.

At the same time, Stout called the string of Legionella outbreaks at the Quincy home “an unusual circumstance."

“It certainly makes you scratch your head a little bit about what’s going on,” she said.

Another water safety expert went even further, saying in 30 years of studying water contamination issues across the country, he could not recall another instance where people contracted Legionnaires’ disease at the same location over three straight years.

But Olson, who has studied lead- and Legionella-contaminated water in Flint, Michigan, and has testified on Capitol Hill about water safety, said he would have qualms about putting his own loved ones at Quincy given the pattern of Legionnaires’ cases.

“If I had … an elderly relative or someone that was immune-compromised in one of those facilities, I would be worried,” he said.

For her part, Jeffries, the state’s Veterans’ Affairs director, said she would have no concerns whatsoever about recommending one of her parents live there. “I would, without hesitation,” she said.

The home’s water treatment facility, she said, has been rebuilt “from the ground up,” including new water heater tanks in every building. Special $150 filters designed to screen out Legionella are attached to every shower head and sprayer and replaced monthly.

“I believe our water is probably the cleanest water in the state without hesitation,” she said.

Jeffries said one reason the facility continues to get positive test results for Legionella is because of how aggressively the state is looking for it and because it is a common, naturally occurring bacteria.

“If you look for it, you are guaranteed to find it,” she said.

Asked if it was possible the facility ever could be fully free of Legionella so long as its suspect, original plumbing system is in place, Jeffries answered, “Probably not.”

“The ironic part is Steve spent the greater part of the rest of his dad’s life, trying to prove his dad was alive, only to prove he was alive and then he passed,” Deann French said.

The couple said there has been little outreach from the state, other than what Steve French characterized as a “form letter” from the head administrator at the facility offering “just a very generic, ‘sorry for the passing of your relative.’” There has not been outreach about Legionnaires’ or explanation for the home’s delayed recognition of his mother’s death, he said.

And then there was one other piece of mail.

“I remember when we opened mail after she died that came from Quincy, and we thought it was going to be some sort of apology that she was dead,” Deann French recalled. “It was a past-due notice on what was owed for her portion of living there.

“And, of course, she hadn’t paid it because she was dead,” she continued. “It was insult to injury at that point.”

In August 2016, the Frenches filed a personal injury suit against the state of Illinois with the court of claims. But their case, like the others that have been filed, has not been decided.

Jeffries, the state Veterans’ Affairs director, said Dolores French lived in the facility’s independent living section and thus was not receiving regular, skilled nursing visits from staff. Jeffries called the French case “a terrible tragedy.”

“Mr. French’s story is Mr. French’s story,” she told WBEZ, when confronted with Steve French's version of events.

Pressed if she had any reason to doubt any aspect of his account and to answer why the staff would say Dolores French was safe when she was likely dead, Jeffries said, “I really can’t answer that because I don’t have the details, and I’m not going to answer a question I don’t have the details on. I really don’t know.”

At this point, the state is accepting no legal responsibility for the 2015 Legionnaires’ outbreak, according to filings with the court of claims.

“As we move forward, we will be guided by the facts, and our focus will be to make sure that the resolution is fair,” said Annie Thompson, a spokeswoman for Democratic Attorney General Lisa Madigan, whose office is representing the state Veterans’ Affairs department in the families’ lawsuits.

None of the family members interviewed by WBEZ said they were pursuing the claims for the relatively meager award, which state law caps at just $100,000. Instead, they say want to see the problem solved. And they’re incredulous that the problem hasn’t been fixed yet by the state, with each new case forcing them to relive their own personal horror.

Casper’s sister, Brenda Sprague, then jumped in.

“These are people who served our country. They are the ones who support our freedom today, and to think this is the way they go out, it’s just really, really hard. We had an awesome dad,” Sprague said. “It was hard to watch the strong man that he was die the way he died.”

Neither the Kuhn family nor Tucker family want to see the Quincy facility permanently close, but they want a greater commitment from the state to eradicate the threat of Legionella. Steve French questioned why the facility is still open.

To date, it’s unclear whether anyone has lost their job as a result of decisions that were made from the summer of 2015 forward. The state’s Veterans’ Affairs department didn’t respond to a follow-up question.

But Sens. Durbin and Duckworth, who headed the state Veterans’ Affairs department from 2006 to 2009, have called for a “review of [state Department of Veterans’ Affairs] leadership given this troubling pattern of the presence of Legionella at IVH Quincy three years in a row.”

In an interview with WBEZ, Duckworth said, “Something needs to be done. And maybe this is the next step to figure out who has allowed this failure to continue. And at the end of the day, the state director and the governor are responsible.

“No veteran and no family member deserves to go through this,” said Duckworth, a disabled Iraq War veteran who said she hopes to live out her final days in a government-run veterans' home. “It simply is not acceptable.”

Jeffries, who has been Veterans’ Affairs director since 2015, defended her agency’s handling of the situation at Quincy, particularly during the first outbreak when no protocols existed on how to handle Legionnaires’ cases. She said she disagrees with Duckworth’s criticism of the department.

“We had not until that time had any diagnoses of Legionnaires’,” said Jeffries, referring to the 2015 outbreak. “So, because of that, that was not the protocol that we did. So no, I don’t think it was a failing. I think our job and what we did was to provide the highest quality care that we could and that is available, and that’s what we did.”

She acknowledged the anger that some families continue to feel and said the agency is “very sorry for the loss of every single one of our residents.” She also said she sent handwritten letters to representatives of each family with a dead loved one in the 2015 outbreak and attempted calling them. Family members interviewed by WBEZ said they did not recall getting such correspondence from her personally.

She insisted the home and its staff remain highly attuned to the needs of residents there.

“Our staff members know their names. They know their children's names. They know how they like their eggs. They know whether they like to be with extra blankets or a fan. They know the ins and outs of these folks, and they care for them and they love them,” Jeffries said.

But as Legionnaires’ cases continue to accumulate, the Frenches agreed the state needs to do more to prevent further outbreaks.

“You know what he should do?” Deann French said of Gov. Rauner. “He should go back over there and he should drink some of the water. Or maybe he should take a shower. Or maybe he should eat off of one of those plates coming out of that kitchen. Maybe that would make an impact on him.”

Bottom line, Steve French said, someone has to answer for what happened — and is continuing to happen — at the Quincy veterans’ home.

“People are dying. Something’s killing them. Granted, it’s a water-treatment problem. But it’s killing people,” he said. “Shouldn’t somebody be held accountable?”

This story has been updated to change a reference to the date of the first-known case of Legionnaires' disease during the 2015 outbreak, which showed up on July 24.

Dave McKinney and Tony Arnold cover state politics for WBEZ. Follow them on Twitter at @davemckinney and @tonyjarnold.