For nearly two years, tests showed that the water at a Southeast Nebraska nursing home was contaminated with deadly Legionella bacteria that sickened multiple people and killed at least one person.
Yet state, local and facility officials bogged down, month after month, as they tried to find a solution they could all agree on to address the contamination at Colonial Acres of Humboldt. Home administrators made attempts to mitigate the problem — which was first reported to the state in September 2022 — but the bacteria kept returning.
Finally in May, at the state’s request, the federal government intervened. The U.S. Environmental Protection Agency quickly ordered emergency action — calling the situation in Humboldt an “imminent and substantial endangerment†to the health of the nursing home’s elderly residents.
It’s not clear exactly how many people died from the bacteria, which can cause Legionnaires’ disease. The EPA order said one death occurred in March, while also referring to “fatalities.†Colonial Acres officials told the Omaha World-Herald they could not confirm if any additional deaths could be attributed to the bacteria. But they said four residents came down with Legionnaire’s disease.
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Now Humboldt has installed a new chlorination system to disinfect the water going into its city-owned nursing home, as ordered by the EPA. That’s expected to provide a long-term solution.
Still, the federal investigation made clear that the lengthy process of getting to this point had left Colonial Acres residents exposed to dangerous conditions for many months.
In its May 20 order, the EPA said previous steps taken by state and local authorities had not been “adequate, timely or otherwise sufficient.â€
Matt Ross, vice president of Rural Health Development, which manages the city-owned Colonial Acres, said he was happy with the outcome of the order, which he said “solidified†what had been “on our radar†before.
“We think of it as a collaborative decision,†Ross said. “It looks like we’ve got a solution that’s going to fix the problem.â€
Former Humboldt Mayor Rhonda Dettmer said the parties had been “working toward†that solution previously. The City Council approved the purchase and installation of the disinfection system the day after the EPA order was issued.
Legionella outbreak at Humboldt facility began in 2022
She said Colonial Acres is valuable to Humboldt, a town with just under 800 residents. The home, which has 49 nursing home beds and 16 assisted living apartments, is Humboldt’s largest employer. In addition, most local residents have personal ties to the home.
“Everybody’s got people up there,†she said.
Legionella bacteria can cause two types of respiratory diseases: Pontiac fever and the potentially fatal Legionnaires’ disease. The bacteria is commonly found at low levels in groundwater, lakes, streams and other bodies of water. It can become problematic if it gets into water systems and grows.
Infections occur when people breathe in contaminated mists, such as those produced by shower heads, faucets and nebulizers. Infections also can happen if people aspirate, or get water in their lungs, while drinking. People with existing health problems, such as those in nursing homes, and those over age 50 are at greater risk of getting sick.
The Nebraska Department of Health and Human Services reported 163 cases of Legionella in the state from 2020 through the current year, including seven deaths. Three of the seven deaths occurred in the Southeast Health District, which includes Humboldt. No other local health district had more than one death during that period.
Nationally, an estimated 8,000 to 18,000 people are hospitalized with Legionnaires’ disease each year, according to the U.S. Centers for Disease Control and Prevention.
The Legionella outbreak at Colonial Acres began in 2022. According to the EPA order, the State Departments of Environment and Energy and Health and Human Services learned about the situation in September of that year. HHS licenses nursing homes and assisted living facilities and investigates reportable disease outbreaks. NDEE regulates drinking water.
Neither state agency would respond to questions about that outbreak or their actions regarding it, saying state law makes reportable disease cases and investigations confidential.
However, HHS spokesman Jeff Powell said Legionella cases must be reported to the state. Officials then investigate and typically work with communities to take mitigating steps. He said such steps are especially critical when Legionella occurs in a health care facility and endangers more vulnerable people.
“The State of Nebraska takes these cases very seriously and its agencies work collaboratively with each other, local governments, facilities and other stakeholders to mitigate and prevent this or any threat to the health and safety of Nebraskans as quickly and effectively as possible,†he said.
Powell said HHS works to ensure that health care facilities have a comprehensive water management plan in place to deal with Legionella. The agency considers facilities to be in compliance with state and federal licensure regulations as long as they follow that plan and implement recommended mitigation measures.
A World-Herald review of recent Medicare inspections done by state surveyors at Colonial Acres found no mention of the Legionella contamination or of any water concerns.
Mitigation efforts but ‘no routine disinfection’
Colonial Acres Administrator Betsy Packett said the facility had taken numerous steps to address the contamination. Those included regular testing for Legionella throughout the facility and five rounds of chlorine “shock†treatments, which use very high levels of chlorine to kill bacteria.
She said the water lines were being flushed at least twice a week and up to five times a week recently. The home replaced many fixtures and added a hot water recirculation pump. In addition, the home had been running water heaters at higher temperatures to inhibit bacteria growth, which then required the addition of mixing valves on every fixture to keep water coming out of the faucet at a safe temperature.
For a while, the home also installed filters on shower heads. But Packett said the filters were costly and had to be replaced every three months. They also were unpopular because they severely reduced water pressure. For those reasons, she said, the facility stopped using the filters for several months, but installed a new round after the death in March.
“Despite efforts to mitigate the contamination, samples collected in March 2024 showed the presence of Legionella in the water throughout the Colonial Acres facility. There is currently no routine disinfection treatment of water used at the facility,†the EPA said.
Ross said the mitigation measures helped some, but the numbers of bacteria rebounded each time. Powell acknowledged the difficulty of such situations.
“Once Legionella is identified in a water system, permanently eliminating the bacterium can be challenging,†he said. “In many situations, continuous efforts are required to keep Legionella growth under control.â€
Earlier this year, Packett said, it became clear that a permanent solution was needed. She said state officials recommended two options, either have the town of Humboldt start chlorinating its entire water supply or install a chlorination system just for Colonial Acres.
The city balked at the idea of chlorinating the whole town.
Dettmer, who resigned as mayor in early June, said Humboldt has maintained good quality water for decades without chlorination. She said their engineer advised that adding chlorine to a system with old pipes would cause the water to come out brown for six months. She said they were also told it would take more than the normal amount of chlorine to help the home.
Tests showed that there was no Legionella contamination in the city water supply outside of Colonial Acres, although the EPA order noted there were no backflow devices to prevent the bacteria from infecting the rest of the water system.
But installing a system just for Colonial Acres could make the facility a regulated public water system and require it to meet state and federal drinking water regulations, Powell said. The installation itself was estimated to cost about $85,000, Dettmer said.
According to the EPA, a May 14 meeting of representatives from the state, the home and the city had ended with no commitment by city officials to pursue any of the potential options. After more than a year of effort, and at least one death, they still hadn’t agreed on a long-term plan to disinfect the nursing home’s water.
Six days later, the EPA ordered them to do the work.