Every finding on record at Curo Health Services, LLC

Upon patient record review 2 of 19 (Patient #5,6) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient 5: There was no evidence of a spiritual care assessment of the patient/caregiver. Chaplain services were declined at the time of admission. There is no evidence that the RN or the SW completed this part of the assessment. Completed during survey. Patient 6: There was no evidence of a spiritual care assessment of the patient/caregiver. Chaplain services were declined at the time of admission. There is no evidence that the RN or the SW completed this part of the assessment. Completed during survey.

Upon patient record review, 1 of 19 (Patient #14) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient 14: The patient was admitted on 12/11/25. There was no evidence a bereavement risk assessment was completed within 5 days of admission. The assessment was completed on 12/18/2025.

Upon patient record review, 1 of 19 (Patient #9) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient 9: No evidence that a RN comprehensive assessment was completed every 15 days between 10/31/2025 and 11/21/2025, 21 days between assessments.

Upon patient record review, 1 of 19 (Patient #3) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 3: The aide documented on 01/05/26 that the patient had 2 skin tears to the patients right arm. The aide documented that she informed the nurse. No evidence that the nurse assessed the skin tears at the time that the chart was surveyed. Late data entry occurred during survey.

Upon patient record review, 2 of 19 (Patient #3,14) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 3: The medical record indicated that the patient has chronic UTI's and takes a prophylactic antibiotic daily. No evidence that problems, goals, and interventions related to infections were added to the current plan of care. Corrected on site. Plan of care updated during the survey. Patient 14: The RN admission documentation indicated that the patient is at high risk for falls. No evidence that the problems, goals, and interventions related to fall safety was added to the current plan of care. Corrected on site. Plan of care updated during the survey.

Upon patient record review, 1 of 19 (Patient #3) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 3: SW and SC frequency was listed as PRN only without a standing order on the initial evaluation order. Order corrected once the disciplines completed their evaluations.

Upon patient record review, 2 of 19 (Patient #13,14) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 13: RN narrative documentation indicated that the patient used a Hoyer lift for all transfers. No evidence that the Hoyer lift was added to current DME supply list. Corrected on site. Plan of care updated during the survey to include the Hoyer lift. Patient 14: Active plan of care has active orders for oxygen. No evidence that oxygen or oxygen supplies added to the current supply list. Corrected on site. Plan of care updated during the survey to include the oxygen and supplies.

Upon client record review, 3 of 19 (Patient #7,11,16) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 7: The plan of care has an order for massage therapy to eval and treat written on 11/18/2025. No evidence that an evaluation or treatment was completed at the time of survey. Patient 11: The plan of care has an order for music therapy eval on 11/24/2025. No evidence that an evaluation was completed at the time that the chart was surveyed. Patient 16: The patient was discharged on 12/16/25 with no documentation that the patient was notified of discharge prior to discharge visit. There were problems/goals/interventions for discharge planning but no evidence the plan of care was followed.

Upon patient record review, 1 of 19 (Patient #16) did not have evidence that the IDG documents the sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement. Patient 16: The patient was discharged on 12/16/2025. No evidence that the members of the IDG team were notified of the discharge before the day of discharge. No mention of patients discharge in any RN or MSW IDG notes before the IDG that occurred on 12/17/25, which was one day after the patient was discharged.

Upon observation, there was no evidence the hospice investigates all adverse events, incidents, accidents, variances or unusual occurrences that involve patient care and develops a plan of correction to prevent the same or similar event from occurring again. Patient 9: RN documentation on 11/09/2025 indicated that the patient's son had a complaint, stating that the staff was unreliable and unpredictable. RN documented that she notified office management of the complaint. No evidence that an investigation was completed at the time the chart was surveyed. Corrected on site with late data entry.

Upon patient record review 2 of 19 (Patient #11,12) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 11: The plan of care has orders for the aide to start on 11/23/2025 at twice a week. No evidence that aide services were provided to the patient until 12/04/2025. Corrected on site with late data entry. Also the aide plan of care had orders for the patients linens to be changed weekly. Aide documentation indicated that it was completed at all visits except the visit that occurred on 12/22/25 and 12/24/25. Patient 12: The plan of care has aide frequency ordered as 3 times a week. No evidence that 3 visits were completed for the week of 01/12/2025. The aide documented that the visit was missed due to "other". No evidence that the visit was missed at the request of the patient/caregiver. Corrected on site with late data entry.

Upon patient record review 3 of 19 (Patient #1,2,11) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient 1: The medical record indicated that aide visits started on 11/05/2025. No evidence that aide supervisory visit was conducted until 12/12/2025 and not again until 12/30/2025. Patient 2: The medical record indicated that aide visits started at the time of admission. No evidence that aide supervisory visit was conducted between 12/05/2025 and not again until 12/24/2025, 19 days. Then again between 01/01/2026 and 01/16/2026, 15 days. Patient 11: The medical record indicated that aide visit was scheduled as once weekly. No evidence that aide supervisory visit was completed every 14 days between 10/31/2025 and 11/21/2025.

Upon patient client record review, 2 of 19 (Patient #6,14) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 6: The NP documented that the patient was a DNR on the face-to-face that occurred on 10/29/25 and 12/13/25. The signed advanced directives and RN documentation indicated that the patient was a full code. Patient 14: RN documented an aide supervisory visit on 01/01/2026 and documented that the patient was receiving aide visits once a week in the IDG note that occurred on 12/31/2025. The medical record indicated that the patient was not receiving aide services since admission. RN documented LVN supervisory visits on 01/22/25 and 01/29/25. No evidence that a LVN completed visits for the patient since admission.

Upon client record review, 1 of 19 (Patient #8) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient 8: The plan of care had SN frequency ordered as twice a week starting 11/23/25 and the volunteer frequency ordered as twice a month starting in November 25. No evidence that 2 visits for the RN week of 12/14 or that volunteer 2 visits were completed for the month of Jan 2026 at the time that the chart was surveyed. RN documentation stated that the 2nd visit was missed due to SN illness and other staff out.

Upon patient record review, 1 of 16 (Patient #13) did not have evidence that if a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patient's rights to the extent allowed by state law. Patient 13: The medical record contained an election form and consents, signed by a niece identified as the POA. There was no evidence of legal documentation to validate the niece's legal authority in the record.

Upon patient record review 1 of 16 (Patient #5) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient 5: There was no evidence of a spiritual assessment in the medical record. The initial RN assessment did not identify patients religion or ongoing spiritual needs other than referral to chaplain.

Upon patient record review, 3 of 16 (Patients #7,#10,#11) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 7: The medication profile contains oxygen with no defined delivery method. Corrected on site. Patient 10: The medication profile contains oxygen with no defined delivery method. Corrected on site. Patient 11: The medical record contains nursing documentation 1/30/23 identifying patient use of oxygen. There was no evidence of oxygen listed on the medication profile. The medication profile contains nitroglycerin sublingual tablets every 5 minutes as needed for chest pain. There was no instructions for maximum consecutive doses. Corrected on site.

Upon patient record review, 2 of 16 (Patients #5,#7) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 5: The medical record contains an order for catheter insertion. There was no evidence of problems, goals, and interventions related to the need for a catheter. Corrected on site. Patient 7: The medical record contains nursing documentation 11/19/22 identifying patient issues with dyspnea and 1/20/23 identifying insertion of an indwelling catheter. There was no evidence of problems, goals, and interventions related to the need for a catheter and respiratory dysfunction. Corrected on site.

Upon patient record review, 4 of 16 (Patients #5,#7,#10,#11) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 5: The medical record contains an order to insert a Foley catheter 1/20/23. There is no evidence of instructions for size, maintenance, and change frequency included on the order. Corrected Patient 7: The medical record contains an order for oxygen with no defined delivery method. Corrected. Patient 10: The medical record contains an order for oxygen with no defined delivery method. Corrected. Patient 11: The medical record contains nursing documentation 1/30/23 identifying patient use of oxygen. There was no evidence of an order for oxygen. The medical record also contains an order for nitroglycerin sublingual tablets every 5 minutes as needed for chest pain. There was no instructions for maximum consecutive doses. Corrected.

Upon patient record review, 2 of 16 (Patients #3,#7) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 3: The medical record contained nursing documentation 12/16/22 identifying patient use of a walker for ambulation and 1/27/23 identifying use of a nebulizer. There was no evidence of the walker and nebulizer included as DME on the plan of care. Corrected on site. Patient 7: The medical record contains nursing documentation upon admission identifying patient use of a walker for ambulation. There was no evidence of a walker included as DME on the plan of care.

Upon client record review, 1 of 16 (Patient #7) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 7: The medical record contains nursing documentation 1/20/23 identifying insertion of an indwelling catheter. There was no evidence of an order for a catheter.

Upon patient record review 1 of 16 (Patient #6) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient 6: The medical record contained nursing documentation upon admission identifying the patient would enjoy volunteer services. There was no evidence of a volunteer assessment completed or referral made for services. Corrected on site.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient 1: Upon observation during the home visit, the RN did not use a barrier beneath their bag that was set on a side table per bag technique policy.

Upon patient record review 2 of 16 (Patients #10,#11) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 10: The medical record contained an ordered aide frequency for twice weekly. There was only 1 missed visits recorded and no completed visits for the weeks of 1/8/23, 1/22/23, and 1/29/23. Patient 11: The medical record contained an ordered aide frequency of three times weekly. There was only 1 missed visit recorded and no completed visits the week of 1/22/23 and 1 visit completed and no missed visits documented the week of 1/29/23.

Upon patient record review, 1 of 16 (Patient #16) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patient 16: The verbal certification of terminal illness was received 10/7/22 for benefit period starting 10/4/22. Agency did not bill for missed days due to error.

Upon patient client record review, 1 of 16 (Patient #15) did not evidence that each patient record contains physician orders. Patient 15: The medical record indicated the patient was discharged for move out of service area. There was no evidence of an order to discharge.

Upon personnel record review, 1 of 14 (Personnel #10) did not have evidence that all personnel have been fully vaccinated for COVID-19.

Based on policy review, record review, and interview, the agency failed to promote and protect the following care to patient of a SNF/NF or ICF/MR (now called ICF/IID): - 418.112 (e)(3) Provide the SNF/NF or ICF/IID with the following information: - (ii) Hospice election form and any advance directives specific to each patient. (L781) The cumulative effect of this deficient practice resulted in a finding of immediate jeopardy for one patient (Patient/Record #1) and has the potential to affect all patients served by the agency.

Based on policy review, record review, and interview, the agency failed to provide an updated coordinated plan of care (POC) to the nursing facility where the patient resided, that identified the advance directive showing the patient's desired full code status in the event of cardiac arrest, in one (Record/Patient #1) of one discharged record reviewed. This deficient practice has the potential to affect care of all patients served by the agency. Findings included: Review of agency's policy 510 titled, "DO NOT RESUSITATE," dated 07/2009, showed: Through written or verbal statements, patients exercise their right to accept or refuse life-prolonging procedures. A patient is not required to have a do not resuscitate (DNR) order to be admitted to Heartland Hospice (AKA Promedica Hospice). PROCEDURE: - The registered nurse meets with the patient/family to explain and discuss patient's right to self-determination and review heartland's policy on Advanced Directives/DNR; - Copies of Advanced Directives and/or DNR orders are placed in the patient record; and - Original "Do Not Resuscitate" order written by patient's physician is kept in patient record. Review of the agency's policy titled, "Coordination and Communication," dated 2021, ProMedica Hospice Facility Guidebook showed: - A designated hospice registered nurse (RN) will coordinate the integration and implementation of the plan of care. The facility must identify a representative from their interdisciplinary team to collaborate with the hospice RN in developing the integrated plan of care; - Care plans are implemented, evaluated and updated to meet identified needs of the patient as changes occur. Changes are discussed with the patient, family, caregiver and facility staff. Procedures are in place to ensure patients receive medication and treatments for optimal palliation. Hospice and facility staff coordinate care to assure the patient does not experience a delay in receiving needed medications and treatment. Hospice and facility staff determine the process by which information is exchanged when developing and evaluating outcomes and updating the plan of care to assure patients receive necessary care and services. Both teams seek input from the patient and caregiver on desired goals; - For optimum patient and family care, the facility and hospice work closely together in the following: - Collaboratively developing and implementing an interdisciplinary plan of care; - Jointly participating in the patient's care conference; - Frequent communication with any change of condition, new orders or family needs; - Time-of-death notification and communication; and - The hospice and facility must have a process for shared communication between both entities. Review of the agency's undated policy titled, "Individualizing the Hospice Plan of Care Guidebook," showed: - The mission of hospice is to provide quality hospice care to patients with a terminal illness and to support their caregivers; - The plan of care (POC) is one of the most important items the hospice team develops and guides the care provided to each patient. Agencies comply with policies, federal and state regulations and accreditation standards; - The hospice interdisciplinary group (IDG) creates the POC in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient's needs; - Development of the POC begins with the comprehensive assessment; - Needs may be identified in the comprehensive assessment that are not related to the terminal illness and related conditions. The assessment documents that the hospice is aware of these needs and if warranted, notes who is addressing them. The hospice ensures that each patient and the primary caregiver(s) receive education and training as appropriate to their responsibilities for the care and services identified in the POC; - The IDG reviews and revises the POC based upon review of the updated comprehensive assessment and the patient's changing needs. Each discipline involved in the patient's care contributed to each IDG discussion and participates in updating the POC based on the patient and family's current needs. The POC is a "work in progress"; - The initial POC includes, but is not limited to: * Drugs and treatments necessary to meet the needs of the patient; * End-of-life care preferences; - A POC must be established before care is provided and periodically reviewed by the attending physician, the hospice physician, and the IDG group; - Patient preferences for end of life care are assessed and included in the POC. This includes funeral home preferences, advance directives, and living wills; - Like home patients, facility patient's POC's are individualized according to each patient's needs. The hospice team and facility staff communicate, establish, and agree upon a coordinated POC for both providers which reflects the hospice philosophy, and is based on an assessment of the patient's needs and unique living situation in the facility; - The integrated plan identifies care and services which the facility and hospice are going to provide. The POC is revised and updated as necessary to reflect the patient's current status; and - Critical thinking skills are essential when developing a POC. The hospice POC is individualized based upon the comprehensive assessment. Each time a patient is admitted or recertified, a POC is developed or updated based upon the current needs. RECORD/PATIENT #1: Review of the clinical records showed the following: - An "Outside the Hospital Do-Not-Resuscitate Order" signed in the box for revocation of DNR status on 05/03/2021 by the patient, and signed by the physician on 05/07/2021; - Patient was admitted to hospice services on 06/03/2021; - Admitted with a terminal diagnosis of severe protein-calorie malnutrition; and - Patient resides in a long-term care facility. Review of the RN comprehensive assessment dated 06/03/2021, showed: - DNR preference confirmed with patient; - Alert and orientated to person, place and time; and - No abnormal cognitive functions identified. Review of the master of social worker (MSW) comprehensive assessment dated 06/08/2021, showed patient alert and oriented to person, place and time. Review of the hospice POC dated 06/02/2021 to 08/30/2021, showed: - Start of care 06/02/2021; - Skilled nurse twice a week times one week, one time a week times 12 weeks and as needed; - Hospice nurse to coordinate POC with long-term care facility [LTCF] staff; and - Advance directives - Do Not Resuscitate. Review of the RN comprehensive assessment dated 10/23/2021, showed: - DNR preference confirmed with patient; - Alert and orientated to person, place and time; - No abnormal cognitive functions identified; - Lives in a long-term care facility/nursing home; - Readmitted to Heartland [Promedica] hospice on 10/23/2021 with a diagnosis of protein calorie malnutrition. Patient had a fall out of bed on 10/20/2021 and was sent to the emergency room, where he/she was diagnosed with a right femoral fracture. He/she was subsequently discharged from Heartland [Promedica] hospice to receive surgery. Surgery was then declined by patient. The patient returned to the LTCF on 10/22/2021; and - Received report from the LTCF charge nurse and obtained copy of recent hospitalization records and copy of code status form dated 09/13/2021, indicating the patient is a full code. Review of the POC dated 10/23/2021 to 12/01/2021, showed: - Start of care 10/23/2021; - Skilled nurse once a week times one week, two times a week times one week, once a week times seven weeks and as needed; - Hospice nurse to coordinate POC with LTCF staff; and - Advance directives - Do Not Resuscitate; None. Review of the hospice MSW documentation showed that: - On 10/25/2021 the MSW visit showed: * Patient reports "I'm not gonna die. I hope for a miracle. One part of my life is to have miracle." Licensed clinical social worker (LCSW) spoke with patient regarding code status and patient reports a preference to remain a full code at this time. LCSW advised LTCF nurse, hospice RN case manager and hospice spiritual counselor coordinator, of the above mentioned details. Patient will likely benefit from ongoing hospice support and education; and - On 12/01/2021 the MSW visit showed: * "I am not afraid to die. We are all going to do it. I don't want to die but I am not afraid." Patient deceased at LTCF on 12/12/2021. Review of the hospice agency, "Investigation Report," dated 12/13/2021 to 12/14/2021 showed: - On 12/12/2021, hospice notified that patient had passed away; - On 12/13/2021, hospice Senior Director of Professional Services (DPS) spoke to the LTCF administrator and he/she was informed the LTCF agency nurse had not initiated CPR [cardiopulmonary resuscitation - an emergency procedure that can help save a person's life if their breathing or heart stops] on the patient, and he/she was a full code. The LTCF agency nurse had not looked at the facility chart, but had looked at "hospice paperwork" that showed patient was a DNR; - Conclusion: There was conflicting documentation in the patient's clinical record regarding the Outside Hospital DNR form that was signed in LTCF in May 2021 (prior to first hospice admission), and a code status form indicating full code that was signed on 09/17/2021. The hospice POC order for hospice admission date of 10/23/2021 indicated "Do Not Resuscitate" and this was signed by the hospice physician and attending physician, but there was also documentation by the RN and MSW (found in their comprehensive assessments) that the patient's wish was to be a full code. The LTCF agency nurse did not perform CPR, and hospice was notified after patient was already noted to be deceased; and - The discrepancies in the patient's medical record brought to light the urgent need to clarify all patients/responsible parties' wishes for resuscitation or full code, and to ensure that all wishes are communicated to all hospice caregivers and facility staff. Review of the "Witness statement," dated 12/14/2021, showed: - The MSW that completed the admitting assessment on 10/25/2021 was aware the patient was a full code, and he/she documented the patient's wishes in his/her comprehensive assessment, and documented that he/she had informed the hospice team and the [LTC] facility staff was aware; - The RN that made the death visit on 12/12/2021 was not aware the patient was a full code. The documentation in hospice record reflected DNR. He/she was completing paperwork and looking through the facility chart and noticed that the patient was a full code. He/she did not expect the patient's death. He/she had visited the patent on 12/11/2021, because he/she had nausea and obtained new orders and provided interventions. The patient was alert and stable at that time with no signs that he/she would pass away the next day; and - The RN that admitted the patient to hospice on 10/23/2021 was aware the patient wanted to be a full code and he/she documented it in his/her assessment narrative. He/she reviews the facility chart and looks for any advance directives or DNR forms. If the patient is a full code and they don't have another advance directive (DPOA- durable power of attorney) then he/she would indicate "None" in the Advance Directives screen. He/she would not have indicated Do Not Resuscitate if he/she wasn't a DNR when completing the admission. During interview on 01/25/2022 at 1:15 PM, the hospice DPS stated that: - There was a DNR in the patient's chart from May 2021; - After the patient returned from the hospital in October 2021, he/she changed to a full code; - He/she had made hospice staff aware that he/she was a full code after the hospital stay, but it never got changed in the hospice electronic medical record (EMR); and - He/she was a new admit in October, but some things carry over in the EMR, and his/her DNR status carried over and never got changed. During a telephone interview on 01/27/2022 at 1:23 PM, the MSW stated that: - The patient was a full code on admission and wanted to remain a full code on his/her second admission; - When a patient wants to be a full code, he/she talks to the nurse at the LTC facility and tells the hospice nurse the patient wants to be a full code; - He/she saw the nurse had also documented the patient wanted to be a full code; and - He/she doesn't know why the patient slipped through the cracks.