Problem: Ana is an 80-year-old widow who lived alone in a third story economy of a senior citizen complex up until her stroke three months ago. Ana was on the floor in her kitchen for over 12 hours until the neighbor came to find her and called the paramedics.. It was found Anna had blood clots due to undiagnosed atrial fibrillation. Following her stay at an acute care hospital Anna was told she would need to move to rehabilitation facility. Anna was transported to an acute rehabilitation facility where she received physical occupational speech therapies. Each week there was a conference where it was determine whether Honn would continue to benefit from therapy.. therapy was no longer being reimbursed by her insurance contract through Medicare. It would have to leave after two months of therapy was performed. She was informed that her insurance would no longer cover rehabilitation.. unable to return to her condominium due to inability transfer walk or perform activities of daily living without maximum assistance a decision had to be made to where she would go on. It did not meet that criteria for assisted living and she was told that a skilled nursing facility would be needed. Anna did not have long-term care insurance and once her Medicare runs out there will no longer be payment for skilled nursing facility even if she's unable to return to her home. The social service person at the rehabilitation suggested that they apply for Medicaid and provided phone number and website for further information was transported to the skilled nurse facility two days later.. as a professional nurse at the skilled nursing facility what would be your main concern and need for assessment related to Honn his medical conditions and transitions