Family in search of answers, as life comes to an end at Elm Manor

William “Bill” Vishneski Sr. had always been a comedian, bringing laughter and smiles to the faces of almost anyone he encountered.

Serving as a paratrooper during the Korea War, he had always been proud – like his Polish roots.

Even at the age of 91, the proud Polish man had often been seen singing and dancing to classical Polka music.

Although he was a class act comedian, he never had been considered a complainer even about own his medical condition.

“He never was a complainer. He just he just is very mild mannered. That was just him. That was his personality. He wouldn’t say anything to anybody,” Pauline Sowa, Bill’s medical care proxy informed

As a resident from the Vienna Gardens independent care facility in Phelps, Pauline recalled how Toni Lee, his private aide for almost a year and half who helped manage his bed and showers would often end-up playing a game of 20 Questions just to figure-out how he’s feeling each day.

“Toni complained about it. She said you gotta guess everything with him. If he’s still quiet, then I played 20 questions with him. They loved him at the Vienna Gardens,” she recalled.

While Bill had always been the silent type, it hasn’t always been his choice after recently suffering from an undiagnosed stroke during his latest stay at Elm Manor Nursing and Rehabilitation Center in Canandaigua.

“I want to know why he has to go to physical therapy out of the hospital.” – Pauline Sowa

Sowa explained that Bill’s condition started deteriorating from a respiratory-related issue caused by troubled breathing, forcing him to consult medical experts at Clifton Springs Hospital and Clinic.

“The whole situation started on March 3rd. He was at Vienna Gardens in the morning. He was having trouble breathing,” Sowa shared.

Eventually Bill had been moved to Newark Wayne Community Hospital managed by Rochester Regional Health.

“So, I went over in the afternoon, and he was in emergency and he was on a breathing device and the doctor came in and said that he was having breathing difficulties and they were going to take them to Newark Wayne, to intubate them because they didn’t have the equipment at Clifton for that,” she remembered.

Nearly a week passed until Pauline heard any good news when Newark Wayne alerted her that “everything was going good” except for the fact that their medical professionals recommended for Bill to undergo physical therapy.

Their consultation compelled her to visit the physical therapy department at the hospital on Friday, March 13th.

“Well, you know, he’s a little wobbly, and I said, well, I’ll be honest with you, he’s 91 years old, and I don’t understand he’s here for a respiratory issue and now all of a sudden, he needs physical therapy,” Sowa expressed.

She then asked, “I want to know why he has to go to physical therapy out of the hospital,” even though Vienna Gardens offers those same services in-house, according to Lee, Bill’s personal aide.

While there, Pauline kindly asked Bill if he could walk around, which had been met with pure laughter.

“Bill, do you mind walking right now so I can see whether you are walking normal to me or not and he started laughing, and they gave him a walker. He got up, they walked down the hallways, and I could hear they were clanking down another hallway. Then they turned around and they came back, and I was watching them when they came back and looked normal to me,” she insisted.

Sowa also shared that Bill even agreed with her and Lee’s assessment, saying that his legs felt fine and his walker at Vienna Gardens had wheels, which allowed for easier mobility while on his feet.

One of the physical therapy staff pressed that he needs to be able to get out of the bed on his own, so Bill without a walker in-hand, grabbed the bar railing and easily stood up, according to Pauline.

“He gets into bed lays down laughing his head off,” she remembered.

After passing all of the tests that were thrown in his way, Pauline suggested that he should be discharged back from the hospital the following Monday, March 16th.

Both Pauline and Toni planned for his release from Newark Wayne to return into their care at Vienna Gardens that Monday morning, but those plans were put on hold just as soon as she arrived.

“So, I went over there Monday, and I go in his room and it’s empty. I sat in that room for almost an hour. They finally brought him up in the bed, delirious, and the doctor comes in and says, he can’t stand on his right foot,” Sowa said.

Unbeknownst to her, she later found-out that Bill was undergoing X-rays, which were scheduled sometime that weekend after her visit to the facility on Friday.

Newark Wayne informed her that it took two people to place him into a wheelchair, claiming “He needs outside physical therapy. We’ve done everything medically.”

“I said, you gotta be kidding me. There’s something wrong here,” she admitted.

Pauline claimed that physicians considered him incompetent and advised her that she’ll be held liable if she were to move him – which then prompted his move to Elm Manor on Wednesday, March 25th.

“She said he’s not going home. His wounds on his feet are too bad that he can’t go home and hung up on me.” – Toni Lee

Weeks later, Pauline contacted Elm Manor on either April 13th or 14th, explaining to them that she wants Bill to be released back into the care of Vienna Gardens, his true home.

“One of us is going to check them out either going to be he’s checking himself out or I’m checking them out, but I want him leaving and I hung up,” she mentioned.

That’s when Toni, a 32-year certified nurse aide awaited outside Elm Manor on North Main Street that following Friday on April 17th.

Pauline had Elm Manor agree for Bill to be released, but only into the care of properly trained nurse – since his insurance would stop covering his time inside until that date.

At 8 a.m., Toni came prepared with a sit and stand in-hand and simply waited.

“I went to the front door. I waited and waited and waited because we were supposed to do it right inside the foyer because everybody was locked down,” Lee told

“So, I waited for 20 minutes. I called them. The lady answered the phone and I said, ‘I’ve been out here for 20 minutes waiting. I have an eight o’clock appointment to show you how to use the sit and stand so that I can take him home,’ and she said he’s not going home. His wounds on his feet are too bad that he can’t go home and hung up on me,” she recalled.

Still in shock, after not seeing or retrieving Bill – she frantically called Pauline, asking what were the wounds that this woman had been talking about.

Prior to traveling to Newark Wayne for his respiratory issues, Toni confirmed that he entered their facility without any wounds on his feet, long before ever arriving to Elm Manor for rehab.

“Nobody has said anything about him and any wounds before. Him being a diabetic and that he had wounds on his feet, he should have been going to the hospital,” she added.

While staying at Newark Wayne, Bill did suffer from a fall. Both Pauline and Toni visited him and checked his body before the worries over wounds ever became an issue.

“So, Pauline and I went over there, and I yanked the sheet right off of them, and I started from his toes and checked his entire body. There were no bruises. There were no wounds, nothing until you got up to his shoulder and there was a little swollen spot. That was from the fluid on his lung from the respiratory illness that put them in,” Lee added.

“I could tell the few words he said, were all slurred together, and I knew right then and there that he had had a stroke.” – Cathy Goodall

The next week, Pauline called around 10:30 a.m. on Wednesday, April 22nd just to speak with Bill, who still resided inside Elm Manor.

Even though her schedule had been packed with appointments leading-up until midweek because of her profession as an account, she still had a chance to catch-up with Bill, as she normally would on a routine basis – but this time it was different, something wasn’t right.

“I can’t understand a word he’s saying,” she confessed.

After she heard some gurgling from his side of the phoneline for a bit, she hung-up thinking that he’d call back, but this time he actually didn’t.

“He never called me back. I waited about 15 minutes. He never called me back, and I said, now there’s something wrong,” Sowa said.

Pauline then swiftly called Toni, who then reached-out to speak with Bill.

In her medical opinion, Toni spoke with Bill briefly and assessed him, admitting that she wasn’t fully certain, but largely convinced that he suffered from a stroke.

“He needs an ambulance now. He’s had a stroke. I said the way he’s talking in the way he’s responding, he’s had a stroke,” Lee relayed to Sowa.

Calling her back, Toni insisted that this is her honest opinion, even though she could not see him.

“Pauline, you’re not going to believe this. I can’t see him, but I’m 95 percent sure he’s had a stroke. He sounds to me like he has a stroke. If I could see his face, I could know for sure,” she recalled.

Soon after, Pauline called Bill’s daughter, Cathy Goodall, who also contacted him that same date just like how Pauline and Toni both did.

“I was surprised for one that he answered the phone, but I could tell the few words he said, we’re all slurred together, and I knew right then and there that he had had a stroke,” Goodall explained to

Later that same day, Pauline contacted Elm Manor, begging for the Director of Nursing to simply check-up on Bill and to let her know what they unearthed at that time.

But even that simple request could not be completed, and Pauline never heard back from the Director the Nursing, whom she directly spoke with that same Wednesday.

“I said I’m begging you to go down there and check Bill. I think there’s something wrong,” she mentioned.

Pauline even admitted that she couldn’t sleep that entire night.

“They never called me back and they’re gone for the day. I did not sleep at night at all,” she remembered.

“Before you do that, if you choose not to send him, I’ll show up with a sheriff escort to have him removed.” – Kerry Kelly 

It was Thursday, the following day after Bill’s family contacted Elm Manor to check-up on his medical condition after they believed that he suffered from a stroke – and still received no updates since then.

Eventually, Bill’ granddaughter, Kerry Kelly had been told about the developing situation by her mother, urging for her to give a call to her grandfather as well.

“As soon as I had him pick up the phone and heard the first three sounds out of his mouth. I told him, ‘Sit tight grandpa, I’m going to get you out of there,’ and then I hung up on him. I felt horrible, but I did what I had to do,” Kelly told

Pauline then received a phone call from Kerry that morning around 8 or 9 a.m. and the pair contrived a plan by having Kerry call Elm Manor while tapping Pauline onto the same phoneline.

“So, I gave her the main number then as soon as they answer and you talk to somebody, I’m going to patch you in on the call because you’re his granddaughter, I’m the healthcare proxy. They don’t even have to talk to you, and they won’t because they’re going play every card they can,” Sowa explained.

She then waited for ten minutes, and then the phone rings – and its Kerry, but she had gotten stonewalled by an unidentified staff member who allegedly said, “Well, I don’t have to tell you anything.”

But then Pauline chimed in, announcing herself on the call stating, “Whatever this young lady says. I’m going to agree with it, do you understand?”

The duo laid down the ultimatum proposition.

“We’re giving you 45 minutes to get him over to the emergency room at Thompson Hospital. If he’s not there in 45 minutes, we’re going to call 911 for an ambulance and tell them to send the ambulance with the Ontario County Sheriff. We think there’s going to be a problem,” Pauline demanded.

“Kerry says, look, the clock is ticking,” she added before they hung-up.

The gauntlet had been issued and the showdown ensued for a brief while until a short fifteen minutes later when Pauline received a phone-call from Elm Manor, notifying her that Bill is being taken for an evaluation heading to F.F. Thompson Hospital.

The end of the call, just like the entire situation both ended abruptly when Pauline claimed, “and then the lady hung up. No bye, no nothing. That was it.”

Unlike at Elm Manor, Kerry finally reconnected with her grandfather for the first time in months through FaceTime calls, even with their personal phones.

“The nurses at Thompson hospital facetimed me when he was put into his room after he arrived there. They used their personal phones and facetimed you from his room so you could see and talk to him,” Kelly shared.

Once he had arrived earlier that morning, Pauline received a phone call around 2 p.m., and the results weren’t good – Bill actually suffered from a stroke and several more serious health issues.

“He’s not in very good condition. His kidneys are drier than a bone. We can even give him a fluid treatment because they will shut down. So, we’re going try to stabilize him, do a drip and see what happens,” Sowa recounted from a conversation with staff at F.F. Thompson.

Pauline later informed Kerry around 2:20 p.m. that he got transferred.

But even when Elm Manor sent him to the emergency room after the initial call made by Kerrie and Pauline, “by then it was too late,” according to Toni.

She noted that F.F. Thompson called because her name appeared on his paperwork, informing her about Bill’s chances for being selected as a brain surgery candidate, which ultimately wasn’t the case for him.

“First they had asked Pauline about brain surgery. Then they called Pauline back and said he was not a candidate. So, then I called them and said I want to know what’s going,” Lee mentioned.  

Instead of undergoing brain surgery, the staff sought to introduce a blood buster with aspirin, only after finding-out that the test results still came back negative about whether he’d qualify for the necessary surgery.

The 32-year medical veteran seemed highly skeptical about why Bill didn’t get the treatment that he desperately needed, which may have saved his life but there’s only a limited time window open for two-hours.

The hospital staff admittedly revealed to her that this was the reason.

“He’s past the two-hour window. We’re looking at 33-hours that he went without medical care,” Lee added.

“He was going into comfort care and had nowhere to go. So, I offered to use my house as a hospice situation.” – Cathy Goodall

A practicing physician at F.F. Thompson alerted Pauline that she needed to start considering comfort care options on the following Monday, April 27th.

With this immense weight on her own shoulders, Pauline couldn’t make a decision since she hasn’t seen him in the flesh since sometime back in mid-March.

After agreeing to place him their own comfort care, Pauline had been allowed to visit Bill at F.F. Thompson immediately within two-hours of her decision.

At the hospital, Pauline could tell that Bill still had his faculties while reflecting on current events about football, and yet he couldn’t hold a spoon or swallow food on his own, forcing staff to liquify his meals.

“He couldn’t do anything,” Sowa admitted.

In a private but brief moment together while in comfort care, Bill confided in Pauline saying that now is the time for him to finally meet Johanna once more, his deceased wife.

She asked, “Are you sick of all the treatments and stuff, and he nodded, yeah. I said, you’re ready to go see Johanna? That is his wife. She passed away about five years ago. He said, yeah. I said, okay. I said that I will do that.”

Pauline also served as the executor to his will and she then resolved his debts and decisions dealing with the allocation of his remaining financial assets.

Three days past until Thursday, April 30th when Pauline received another call from F.F. Thompson, notifying her that he needed to transition Bill into hospice care.

A social worker at the hospital consulted her to explore their options for where he can be placed, but these were few – and really only one option left.

“Naples is closed. Mendon is closed, and she says there’s only one place that will take them. Would you freaking believe they had the nerve to tell me Elm Manor? That is so out of the question,” she vocally aired.

Like Pauline, Kerry had been also shocked to hear that F.F. Thompson suggested to her that Elm Manor would offer hospice care until his death.

“We were very shocked. Pauline and I had many conversations on the phone with the treating physicians at Thompson, and when they suggested that we instantly spoke up, absolutely not,” Kelly explained.

The only alternative had been for Bill to enter hospice care at home – and that’s what they did.

“He was going into comfort care and had nowhere to go. So, I offered to use my house as a hospice situation,” Goodall revealed.  

“It rotted. He had an infection and they never took care of it.” – Toni Lee

It was a family reunion under the worst circumstances.

Bill had been moved to his daughter’s home by an ambulance around 10 a.m. that Friday morning on May 1st.

Kerry, the granddaughter cared for Bill inside her own mother’s house in Shortsville, all the while feeling conflicted that Cathy had to see him in his current condition.

A hospice nurse arrived a half-hour later. She and Kerry both noticed nearly four to five layers of worn-out bandages were unwrapped from around his right foot and leg.

After laying him in an open bed, their first task was “taking them off to see what they were hiding,” according to Cathy – only to uncover yet another ill-timed surprise.

His foot had been rotted out. The smell reeked of an unbearable odor partly due to a massive infection that had been untreated in tandem with his diabetes, which had not been resolved, according to Toni.

“It rotted. He had an infection and they never took care of it. When you’re a diabetic, you have to have the proper medications and you have to have the proper circulation, and obviously, he had neither,” she mentioned.

The diabetic care problem has been a well-recorded one, even for Bill at Elm Manor.

Toni shared that when he entered Elm Manor back in January at the start of this year for an initial short-term therapy visit, his diabetic medications were not in order, but only after reading his discharge papers.

“I could tell you the first time he went to Elm Manor when he came back to me, they could not control his diabetes. Within three days of me having him home, his diabetes was back in check the way it should be. When back at home, the VA had to send me chewable tablets, because the sugar would go down instead of up. He would have to have tablets in case it got too low,” Lee said.

While the nurse and Kerry unwrapped the worn-out gauzes, Toni came to tears and even cried.

“I cried. You don’t see something like that on somebody. If you start to see any type of wound on any type of diabetic, you get it treated immediately. When he got to Kathy’s house for hospice, the nurse didn’t even dare take the bandage off of the other side because it was so far into his foot, which means he had had no care,” she expressed.  

Kerry still remembers the hospice nurse’s reaction to unearthing this shocking revelation alongside the rest of them.

“She was shaking her head and the smell was overwhelming from the foot wounds,” Kelly recalled.

Even when F.F. Thompson released Bill into their hospice care at home, they did not notify Pauline or anyone else about his rotting foot and soring wounds even though he was in their care for several days.

“We were wondering why the hospital hadn’t changed his bandages were figuring those bandages were from Elm Manor, so he was in the hospital the two or three days and looks like they did nothing. No one was even given them a sponge bath or wiping him or putting powder nothing, clearly not,” Goodall claimed.

Eventually the hospice nurse left later that Friday. Kerry and her cousin, who is a certified CNA gave Bill a thorough bath, washing him from head to toe and found more sores, some that were still raw.

“After that hospice nurse left when they went to give him a sponge bath, and we didn’t take pictures of it, but underneath his belly, they call it a belly apron – a fat roll. It was all raw under there. It was totally disgusting,” Goodall remembered.

Caring for Bill became an unforgettably graphic family affair. For Kerry, it truly manifested as a horrific sight to behold, especially for her own mother to bear as well.

“They’re definitely graphic, that you’re never going to forget. I mean, I’ve seen things like that before working in the nursing homes. I’m able to put that behind. With him, I won’t be able to, absolutely not. But I felt bad that my mom had to see all that,” Kelly admitted.

After a long day at her mother’s house, Kerry returned to the house on Saturday and stayed up all night. Speaking from her own professional experiences in the field, she knew that time was simply running-out.

“I could tell it was coming close, so I didn’t leave his side,” she said.

The next day, Bill passed away at 11:03 a.m. on Sunday, May 3rd. His death certificate cited the cause of death as a stroke and listed peripheral vascular disease and hypertension as indirect consequences as well.

“If people got to lose their jobs, we would love to see that. They deserve to lose their jobs.” – Cathy Goodall

Even though Bill had been forced to be relocated to Elm Manor instead of his rightful home at Vienna Gardens, the rumors and reputation still bothered Cathy even though she assumed his latest stay would be short and quick.

“We all heard of the reputation and that so it wouldn’t have been nowhere we would have ever sent in to for any length of time,” she admitted.

Despite this all-important detail, his death had been deemed an unjustifiable one in Cathy’s eyes.

“This should have never happened, and it should have never happened the way it did,” Goodall added.

But now, in the aftermath of his untimely death, Kathy insists that if medical professionals from this industry must lose their jobs, so be it.

“If people got to lose their jobs, we would love to see that. They deserve to lose their jobs,” she shared.

Like mother like daughter, Kerry agrees with Cathy, calling for anyone who worked shifts during that Wednesday through Thursday and signed-off on his routine check-up rounds to be dismissed and have their licenses revoked.

“I want to see every person that interacted and signed-off that they cared for him to lose their license and not be able to be an RN and LPN as CNA, any of that, and I’d like to see that facility shut down personally or a nice hefty fine. That will ultimately shut them down,” Kelly demanded.

Seeing the way that how her grandfather had been treated, Kerry firmly believes that they blatantly didn’t care, as shown through their actions.

“They don’t care. They’re not taking care of him. You’ve got your day shift your afternoon shift and your overnight shift aides who interacted with him Tuesday and Wednesday, and part of Thursday, and nobody picked up on the fact that he had a stroke,” she claimed.

Speaking like many others before her, more inspections are a must in her mind.

“Instead of once a year inspection, they need to be doing quarterly inspections because the minute the state walks into those facilities the white gloves come out everybody starts covering their tracks,” Kelly said.

At the same time, Cathy also mentioned that Elm Manor should be proverbially cleaned-out after resolving their ongoing struggle with the facility following her father’s death.

“The place is not good, whether it needs to be shut down, cleaned out. I don’t know, but it needs something,” Goodall said.

All things considered, Pauline has deemed this entire situation downright elder abuse, and certainly not an inexcusable mistake from Elm Manor or even for F.F. Thompson for that matter.

“Its elder abuse. Its neglect,” Sowa disclosed.

Shortly after his death, Pauline read an article in the Canandaigua Daily Messenger that listed a nursing home hotline to report complaints with facilities in New York state.

On Saturday, May 15th, she called that phone number and recounted the story to her receptionist, who considered the entire situation filled with a series of “serious allegations,” according to Pauline.

The receptionist then informed her that she would alert Ontario County Director of Public Health Mary Beer, who was supposed to directly contact Pauline – but she still hadn’t heard back from the county since.