Form with Patient Information and Facility Choices
STRONG MEMORIAL HOSPITAL
Social Work Division
Placement Patient Information Form
Patient Admitted from:___________________________
Social Worker Unit_____________ Expected D/C________________ Date: Date:
Full Inpatient Admit_____________
OBS Status _____________
Outpatient Status _____________
Previous Hospital Stay within the last 30 days (include dates):________________________________________________
Expected Discharge Disposition: SNF Rehab with D/C: Home Adult Home/ALF_________________ Long Term w/ therapy Long Term Terminal Vent Unit Behavioral Unit
Dementia ( ) Secured Unit ( ) Wander Guard Other ____________________________________
Facility Choices: Please mark in order of preference 1-10 (1 being the first choice)
| |Monroe County: | |
|___Aaron Manor* |___Highlands Living Center* |___Penfield Place* |
|___Baird Nursing Home* |(UR Medicine) |___Rochester Friendly Home* |
|___Brightonian* |___Hill Haven (Rochester Regional Health) |___Shorewinds* |
|___Brighton Manor |___Hurlbut* |___St. Ann’s (Irondequoit) |
|___Creekview |___Jewish Home |___St. Ann’s (Webster)- No rehab |
|___Crest Manor* |___Kirkhaven |___St. John’s |
|___Edna Tina Wilson |___Latta Road East |___Unity Living Center |
|(Rochester Regional Health) |___Latta Road West |(Rochester Regional Health) |
|____Elderwood at Lakside Brockport |___Maplewood |___Wedgewood Nursing Home* |
|___Episcopal Church Home* |___Monroe Community Hospital* |___Wesley Gardens* |
|___Fairport Baptist Home* |___New Roc Rehab & Nursing Center |___Woodside Manor* |
|___Hamilton Manor |___Park Ridge Living Center |Surrounding Counties |
|___Highlands at Brighton* |(Rochester Regional Health) |(see next page) |
|(UR Medicine) | | |
For Placement Office Use Only
Dates Opened: ____________ Date Packet Received____________________________
____________ ____________ Discharge Date_________________________________
____________ ____________ Discharge Facility
____________ ____________ Entered in e-Record Opened in ePartner
Allegany County
___Absolut of Houghton
___Cuba Memorial SNF
___Highland Park
___Jones Memorial Swing Bed Unit
___Wellsville Manor
Cattaraugus County
___Absolut of Allegany
___Absolut of Salamanca
___Gowanda Nursing Home
___Olean General Swing Bed Unit
___Pines of Machias
___Pines of Olean
Cayuga County
___Auburn Nursing Home
___Finger Lakes Center for Living
___Northwood at Moravia
___The Commons on St. Anthony
Chemung County
___Bethany Manor
___Chemung County Nursing Facility
___Elcor Nursing Home
___St. Joseph’s Hospital & Nursing Home
Genesee County
___Batavia Nursing Home
___Batavia VA
___Leroy Village Green
___NYS Veterans Home (SNF)
___Premier Genesee Health & Rehab Center
Livingston County
___Avon Nursing Home
___Conesus Lake SNF
___Livingston County Nursing & Rehab
Ontario County
___Canandaigua VA
___Clifton Springs Hospital & SNF
___Elm Manor
___Living Center at Geneva North & South
___MM Ewing Continuing Care Center
___Ontario Center
Orleans County
___Medina Hospital SNF
___Orchard Manor
___The Villages of Orleans
Revised 4/16/18
Oswego County
___Michaud Residential Health
___Morningstar Residential Care Center
___Pontiac Nursing Home
___St. Luke’s Health Services
___The Manor at Seneca Hill
Schuyler County
___Seneca View at Schuyler Hospital
Seneca County
___Huntington Living Center
___Seneca Nursing & Rehab
Steuben County
___Absolut of Three Rivers
___Bath VA
___Corning Center
___Elderwood at Hornell
___Hornell Gardens
___Steuben Center for Rehab & Healthcare
___Taylor Health Center
Tioga County
___Elderwood Health Care at Waverly
___Riverview Manor
Tompkins County
___Beechtree Care Center
___Cayuga Ridge
___Groton Community Health Care Center
___Kendal at Ithaca (only accepts Life Care Residents)
___Oak Hill Manor
Wayne County
___DeMay Living Center
___Newark Manor
___Sodus Rehab
___Wayne County SNF
Wyoming County
___East Side Nursing Home
___Wyoming County SNF
Yates County
___Homestead SNF
___Penn Yan Manor
-----------------------
*UR Medicine Providers
SW/Placement Office Notes:
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