My mom fell and was in the hospital and rehab for weeks

My mom has severe dementia in her 80s and fell in the long term facility where she was living. After the hospital, they took her to rehab for weeks.

The average rehab stay for her age and condition was 14 days.
The phone number earlier for Medicare (CMS), to have a case manager involved earlier, who called to get my mom discharged because they were not doing rehab over the weekend and she should be transferred back to her home.

A couple of months later my mother became unresponsive. The home called an ambulance and she was taken to the emergency room (ER) where she revived and was fine. The doctors speculated her heart rate went very low in the 30s-40s and then came back up on its own, no treatment.

The difference between a living will and advanced directives, so having a 'Do not resuscitate' (DNR)/no code status, to also have an open discussion with advanced directives documents clearly defined when to call an ambulance, and when to leave my mother, allowing her to go peacefully in her home when it is her time - without invasive treatment.