Need assistance on client. She has CHF, COPY and ulcers on legs. Any advice?

I have been caring for her in an assisted living rehabilitation 24/7 nursing unit.

I have been there just about every day until the last few weeks, when i needed to relax.

She is getting or leaving on day 100 of Medicare, and I do not know how they can state she is cleared to go. This is the situation. She can pay for another few month's on her own funds. Actually much more. She doesn't understand the concept of a dollar and thinks she will be broke.

Since she has been inpatient at the Hospital or the Rehab for almost 3 month's lately, like the last week, she is showing signs of delirium, and things are going wrong with her that normaly don't happen, (i.e. her teeth are falling out), she has lost 10 pounds, and eats as set as she can. Went in at 116, and now at 106. She has stated to me for the first time that I am her only advocate. She has mellowed out completely from the unbearable woman, to the "please don't leave at 8:00pm, I don't like to be alone

Am I looking at the end stages of CHF? She takes 80 mg lasix per day, and she was on pain meds, and just one day after years of taking them said, she is not in pain anymore. I know that isn't true, because her behavior now,is to sleep a lot, she talks much in her sleep and some of it is non sensical, but all of it is surrounding her sickness.

Last week, I took her to one of her many doctors, (they are all connected) Virginia Mason, Seattle, and afterwards, the Rehab is two blocks away, and she said, can you take me somewhere, it was a beautiful day, and it wasn't that far away even though she didn't state why, it was all the places her Husand, Harleigh, whom passed away 11 years ago took her.

I sense a feeling of sadness, is this the final stages of CHF, her skin has been very discolored for month's, thrush in mouth, many many issues.

I am wondering does anyone and i know many do, know what if day 100 hits in the rehab and they haven't hit their baseline?

I do know that she cannot start another hundred days in rehab until 60 days have passed.

Or, should I call a Hospice Nurse.

I am going to be bringing her to her house, and living with her for a while.

Previously before we went to the Hospital on May 30, 2014, she had to have the aid car called three times from April 1, to May 30th.

Suggestions, advice, comments are all very welcome.

I hope that everyone had a great "what is for dinner" that was a great thing to do.

D.

PS She does have a good secondary insurance?