Skip to content
Home » Ontario County » Canandaigua » Family in search of answers, as life comes to an end at Elm Manor

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. Even at age 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 his own medical condition.

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

As a resident from the Vienna Gardens independent care facility in Phelps, Sowa 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. 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.

Although Vishneski 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 the 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 Vishneski’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, Vishneski had been moved to Newark Wayne Community Hospital managed by Rochester Regional Health.

“So, I went over in the afternoon, and he was in an emergency room and on a breathing device. 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 Sowa heard any good news until Newark Wayne alerted her that “everything was going good,” except for the fact that their medical professionals recommended for Vishneski to undergo physical therapy at a nursing home amid the coronavirus pandemic. 

Their consultation compelled her to visit the hospital’s physical therapy department 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 why he’s here for a respiratory issue and now all of a sudden, he needs physical therapy,’” Sowa said.

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. 

While there, Sowa kindly asked Vishneski if he could walk around, a simple request that 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, 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 and looked normal to me,” she insisted.

Sowa also shared that Vishneski even agreed with her and Lee’s assessment, saying that his legs felt fine. His walker at Vienna Gardens had wheels, which would allow for him to have easier mobility while on his feet.

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

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

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

Both Sowa and Lee planned for his release from Newark Wayne to return back into their joint care at Vienna Gardens that Monday morning, but those plans were put on hold just as soon as she arrived at the parking lot.

“So, I went over there Monday, and I went into 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 Vishneski had undergone 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 that “He needs outside physical therapy, we’ve done everything medically.”

“You gotta be kidding me,” she exclaimed. There’s something wrong here.”

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

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

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

Elm Manor eventually agreed for Vishneski to be released, but only into the care of a properly trained nurse – since his insurance would stop covering his time inside there until that date. 

At 8 a.m., Lee 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 Vishneski – she frantically called Sowa, asking about the wounds.

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

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

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

“Pauline and I went over there. I yanked the sheet right off of them, and 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,” she recalled.

“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, Sowa called around 10:30 a.m. on Wednesday, April 22nd, just to speak with Vishneski, 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 Vishneski, 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 end of the phone line for a bit, Sowa 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 now there’s something wrong,” Sowa said.

Sowa swiftly called Lee, who then reached-out to speak with Vishneski. She spoke with him briefly and assessed him, admitting that she wasn’t fully certain, but largely convinced that he suffered from a stroke, in her own medical opinion.

After being in the elder care of Elm Manor Nursing and Rehabilitation Center, William “Bill” Vishneski, 91, suffered an undiagnosed stroke, waiting 33 hours without receiving any medical treatment while his legs started to rot away during his short stay inside the Canandaigua nursing home.

“He needs an ambulance now. He’s had a stroke. The way he’s talking and responding, he’s had a stroke,” Lee relayed to Sowa.

Immediately calling her back, Lee insisted it’s her honest opinion, even though she could not physically see him because of state ordered COVID-19 visitation restrictions. 

“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’s had a stroke. If I could see his face, I could know for sure,” Lee elaborated.

Soon after, Sowa contacted Vishneski’s daughter, Cathy Goodall, who also connected him on that same day.

“I was surprised for one that he answered the phone, but 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,” Goodall believed.

Later that same day, Sowa finally reached-out to Elm Manor, begging for their director of nursing to simply check-up on him, letting her know what everyone unearthed from earlier on.

But even that simple request could not be completed, and Sowa never heard back from Elm Manor’s director of nursing. 

“I’m begging you to go down there and check Bill. I think there’s something wrong,” she remembered telling the nursing home staff.

She even admitted that she couldn’t sleep that entire night “at all” because “they never called me back and they’re gone for the day.”

“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 Vishneski’s family contacted Elm Manor to check-up on his medical condition. They believed that he suffered from a stroke – and still received no updates since then.

Eventually, Vishneski’s granddaughter, Kerry Kelly, had been told about the developing situation by her mother, urging 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

Sowa received a phone call from Kelly that morning sometime around 8 or 9 a.m., the pair contrived a plan by having Kelly call Elm Manor while tapping her into the same conversation. 


“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 to play every card they can,” Sowa explained.

She waited for 10 minutes, and then the phone rings – and it’s Kelly, but she had gotten stonewalled by an unidentified staff member who allegedly said, “Well, I don’t have to tell you anything.”

But that’s when Sowa 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 an ultimatum. 

“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,” Sowa demanded.

“Kerry says, ‘Look, the clock is ticking,’” she ended, before hanging up.

The gauntlet had been issued and the showdown ensued until 15 minutes passed. That’s when Sowa received a phone call from Elm Manor, notifying her that Vishneski is being taken for an evaluation and heading to F.F. Thompson Hospital.

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

Unlike at Elm Manor, however, Kelly finally reconnected with her grandfather for the first time in months through a simple FaceTime call on a nurse’s personal cell phone.

“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 me from his room so I could see and talk to him,” Kelly shared. 

Once he arrived earlier that morning, Sowa received a phone call around 2 p.m., and the results weren’t good – Vishneski actually suffered from a stroke and was dealing with several serious underlying health issues. 

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

Sowa later informed Kelly round 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 Kelly and Sowa, “by then it was too late,” according to Lee. 

Lee revealed that F.F. Thompson called because her name appeared on his medical paperwork. She was informed about Vishneski’s declining chances for being selected as a brain surgery candidate, which ultimately wasn’t the case for him.

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

Instead of undergoing brain surgery, the staff sought to introduce a blood-buster with aspirin, only after finding-out that his test results still came back negative – determining that he wouldn’t qualify for the necessary surgery.

The 32-year medical veteran seemed highly skeptical about why Vishneski 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 brain surgery – only two-hours.

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

“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 Sowa that she needed to start considering comfort care options on the following Monday, April 27th.

With this immense weight on her own shoulders, Sowa 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 in their own comfort care, Sowa had been allowed to visit Vishneski at F.F. Thompson within two-hours of her final decision.

At the hospital, Sowa could tell that Vishneski still had his faculties while reflecting on the latest 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, Vishneski confided in Sowa saying that now is the time for him to finally meet Johanna, his deceased wife, once again.

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

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

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

“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 Sowa, Kelly 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 remembered. 

The only alternative had been for Vishneski to undergo 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 said.

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

It was a family reunion under the worst circumstances.

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

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

A hospice nurse arrived a half-hour later. She and Kelly both noticed nearly four to five layers of worn-out bandages were wrapped 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,” Goodall recalled – only to uncover yet another ill-timed surprise.

William “Bill” Vishneski’s stay at a local nursing home in the midst of the coronavirus pandemic eventually led to the end of his life.

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 Lee. 

“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 need the proper circulation, and obviously, he had neither,” Lee explained. 

The diabetic care problem has been a well-recorded one, even for Vishneski and his short time at Elm Manor.

Lee shared that when he entered Elm Manor back in January at the start of 2020 for an initial short-term therapy visit. She found-out that his diabetic medications were not in order, but only after reading the 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. The Veterans Health Association 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 Kelly unwrapped the worn-out gauzes, Lee 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.  

Kelly still remembers the hospice nurse’s reaction to unearthing this shocking revelation alongside the rest of his family.

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

Even when F.F. Thompson released Vishneski into their hospice care at home, they didn’t notify Sowa 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 and we’re figuring those bandages were from Elm Manor. He was in the hospital for two or three days and looks like they did nothing. No one was even giving him a sponge bath or wiping him or putting powder, nothing, clearly not,” Goodall claimed. 

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

“After the 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 said. 

Caring for Vishneski became an unforgettably graphic family affair. For Kelly, 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, Kelly 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, Vishneski 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 Vishneski had been forced to enter Elm Manor instead of his rightful home at Vienna Gardens, the rumors and reputation of that infamous nursing home still bothered Goodall – even though she assumed his latest stay would be short and sweet.

“We all heard of the reputation. It wouldn’t have been anywhere we would’ve ever sent him for any length of time,” she admitted.

His death had been deemed an unjustifiable one in Goodall’s eyes.

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

But now, in the aftermath of his untimely death, Goodall 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, Kelly agrees with Goodall, 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’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 how her grandfather had been treated, Kelly 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 annual inspections, 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, Goodall 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, Sowa 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.

“It’s elder abuse, it’s neglect,” Sowa disclosed.

Shortly after his death, Sowa 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 a receptionist, who considered the entire situation as a series of “serious allegations.” 

The receptionist said she would alert Ontario County Director of Public Health Mary Beer, who was supposed to directly contact Sowa – but still hadn’t heard back from the county’s leading public health official ever since.