Illinois’ top state auditor on Monday criticized former Illinois Gov. Bruce Rauner’s administration for mishandling a fatal 2015 Legionnaires’ disease outbreak at the state-run veterans’ home, saying top state officials did not initially comprehend the severity of the crisis.

The stinging state audit delivered by Auditor General Frank Mautino dissected how two state agencies neglected to notify residents, their families and the public about the epidemic in its earliest stages. That exposed frail residents to a deadly waterborne form of pneumonia that has been tied to 14 deaths in a series of repeated subsequent outbreaks.

The report also pointed to the mistaken July 2015 release of up to 1,200 gallons of bacteria-laden water into the home’s water system. That water had been contained in an out-of-service hot-water heater that was offline for about 30 days, and its release is a “likely cause of the initial outbreak,” the audit stated.

Additionally, more than a week after multiple Legionnaires’ cases were confirmed, former state Public Health Director Nirav Shah concluded that he did not “think it’s necessary right now” to call in the federal Centers for Disease Control and Prevention to assist in the 2015 outbreak, according to the audit.

At that point, Aug. 28, 2015, two people had died from Legionnaires’, and 29 residents and staff had tested positive for Legionella. By the end of the next day, Shah reversed course and recommended that the CDC be brought in to assist the state, the report said.

Since 2015, 66 residents and eight staff members were sickened in rolling Legionnaires’ outbreaks at the facility, with 13 deaths directly attributable to the pneumonia-like illness tied to Legionnaires’. Another resident died in 2018, several months after being sickened by Legionnaires’.

The audit also hit the state Department of Veterans’ Affairs for being caught flat-footed by the 2015 Legionnaires’ outbreak.

“According to documentation provided by [the veterans’ affairs agency], there were no Legionella policies in place, and there had been no training on Legionella prior to the 2015 outbreak at the Quincy Veterans’ Home,” the audit stated.

The long-awaited audit came after a series of WBEZ reports that began in late 2017 and focused on how the state waited six days from when it knew it had multiple confirmed Legionnaires’ cases at the Illinois Veterans’ Home before notifying the public about the epidemic.

The findings in Monday’s audit bolstered a yearlong WBEZ investigation, which also found Rauner’s office repeatedly overruling its own top experts in order to control and constrict what information was made public about successive deadly Legionnaires’ outbreaks.

After the initial reporting, the Illinois legislature got involved, with the state Senate voting 48-0 in February 2018 to authorize an audit into how the state Department of Veterans’ Affairs managed Legionnaires’ outbreaks at the home in 2015, 2016 and 2017.

Former Illinois Attorney General Lisa Madigan announced in October that her office had opened a criminal investigation into the Rauner administration’s handling of the outbreaks. A spokeswoman for current Attorney General Kwame Raoul said that criminal investigation remains open.

No one has been charged with wrongdoing.

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