**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 50 residents. The sample included three residents. Based on observation, record review, and interview, the facility failed to provide the necessary behavioral care and services for Resident (R) 1, who had moderate cognitive impairment as well as schizophrenia (mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and a history of violence and substance abuse. On 07/07/25, R1 began refusing to take his mental health medications and demonstrated increased behaviors. On 07/10/25, around 11:06 AM, the Social Worker spoke with R1's parental guardian, who shared concerns with R1's history of medication noncompliance, erratic behaviors, and history of substance abuse. At around 03:58 PM, after asking Administrative Nurse D and Administrative Nurse E a question, R1 began kicking the door, stating he wanted to leave the facility, and made threats to kill the staff. The staff provided R1 with an Against Medical Advice (AMA) form (a document signed by a patient who is choosing to leave a healthcare facility against their physician's recommendation), which R1 signed, and allowed R1 to leave the facility. The staff did not involve R1's physician, guardians, emergency services, or law enforcement in an attempt to de-escalate or address the mental health crisis. R1 was gone from the facility, with his whereabouts unknown, for seven days before law enforcement picked him up for attempting to procure alcohol without payment and for erratic behaviors. R1 admitted to the acute hospital with sunburn and dehydration. The facility's failure to provide adequate and appropriate services, including physician and guardian involvement to treat a behavioral health crisis, placed R1 in immediate jeopardy. Findings included: - R2's Electronic Medical Record (EMR) documented diagnoses of need for assistance with personal care, difficulty in walking, muscle wasting and atrophy (wasting or decrease in size of a part of the body), and age-related physical debility. The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of nine, which indicated moderate cognitive impairment. The MDS documented R1 required supervision or touching assistance for hygiene, showers or bathing, dressing, and moving from seated to standing position. The MDS documented R1 required supervision or touching assistance for chair or bed, shower or tub, and toilet transfers. The MDS further documented R1 required supervision or touching assistance for walking. The MDS documented R1 required partial or moderate assistance for car transfers, picking up objects, and going up curbs and steps. The Cognitive Loss / Dementia Care Area Assessment (CAA), dated 07/03/25, directed staff to monitor for signs and symptoms of acute mental status changes to help treat the underlying condition.The Falls CAA, dated 07/03/25, directed staff to anticipate and meet R1's care needs so R1 did not attempt to unsafely perform Activities of Daily Living (ADL) cares without staff assistance. R1's Care Plan revealed the following with their initiated dates:06/27/25, R1 needed assistance with ADLs related to schizophrenia and weakness from recent hospitalization. 07/06/25, R1 had impaired cognitive function or dementia, or impaired thought processes related to psychotropic (alters mood or thought) drug use. 07/06/25, directed staff to monitor, document, and report any changes in cognitive function, specifically changes in decision-making ability, memory, recall, general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status. 07/06/25, R1 was at risk for falls related to impaired mobility. 07/07/25, R1 would work to express and manage his emotions and behaviors. 07/07/25, directed staff to encourage R1 to discuss feelings and monitor his progression or decompensation for continued stabilization.R1's Guardianship documents, dated 01/26/22, recorded By clear and convincing evidence, [R1] is an adult with impairments and lacks the capacity to meet essential needs for physical health, safety or welfare, should not be permitted to make any decisions which affect his person, and the Co-Guardians herein appointed shall be possessed of all the powers and duties of a Guardian as set out in K.S.A. $59-3075 and the Letters of Guardianship to be issued herein shall so state. An Acute Care admission Psychiatric Evaluation dated 05/28/25, recorded R1 had diagnoses of schizophrenia and schizoaffective disorder, bipolar type (a condition that combines symptoms of schizophrenia and bipolar disorder [major mental illness that causes people to have episodes of severe high and low moods]). The document further recorded the hospital requested screening due to R1's behaviors and R1 not stabilizing. The document recorded R1 had not cleared the signs and symptoms of psychosis (any major mental disorder characterized by a gross impairment in reality perception) since 05/01/25. The document recorded R1 repeatedly physically attacked staff and peers; R1 was irritable, delusional, and had not taken medication consistently; R1's parents were his guardians. R1's Kansas Preadmission Screening and Resident Review (PASRR) dated 06/24/25, documented R1 had a history of substance use. The PASRR recommended the following specialized services for R1: community psychiatric support and treatment, crisis services, substance use services, behavioral support services, peer support, and case management.R1's Medication Administration Record (MAR) dated 07/01/25 through 07/31/25, documented R1 refused the following five medications: 1. Divalproex Sodium (medication used to treat bipolar disorder) 500 milligrams (mg), give one tablet two times a day, for hallucinations and delusions. R1 refused the evening dose on 07/07/25, the morning and evening doses on 07/08/25 and 07/09/25, and the morning dose 07/10/25. 2. Haloperidol (medication used to treat various psychiatric and behavioral disorders) 10 mg, give two tablets by mouth two times a day, for schizophrenia. R1 refused the evening dose on 07/07/25, the morning and evening doses on 07/08/25 and 07/09/25, and the morning dose on 07/10/25. 3. Oxcarbazepine (medication used to treat bipolar disorder) 300 mg, give one tablet two times a day, for mood stabilizer. R1 refused the evening dose on 07/07/25, morning and evening doses on 07/08/25 and 07/09/25, and the morning dose on 07/10/25.4. Ziprasidone (medication used to treat schizophrenia) give 80 mg, twice a day, related to schizophrenia. R1 refused the evening dose on 07/07/25, the morning and evening doses on 07/08/25 and 07/09/25, and the morning dose on 07/10/25.5. Buspirone (Buspar) 30 mg, give one tablet by mouth three times a day, for pacing and agitation related to anxiety disorder. R1 refused morning and mid-day dose on 07/10/25.On 07/07/25 at 11:26 AM, a Social Service Note documented R1 approached the Social Worker and insisted staff did not meet with him for an assessment. After a while, he was able to recall meeting with the Social Worker. R1 was asked, What can we help you with at this time? and he responded that he continued to have hallucinations and demanded a change in his medications (would like his Buspar and Haldol increased). The Social Worker informed him it would be passed along to the nurse, and he replied angrily, You need to just call my mom. R1 was supported and reassured that the Social Worker would follow up with the proper staff about his concerns. R1's EMR lacked evidence of follow-up from the social worker. On 07/07/25 at 04:19 PM, a Nurse's Note documented R1 refused all evening medications except Risperdal (medication used to treat schizophrenia). The note documented notifications were sent to R1's doctor and the Advanced Practice Registered Nurse (APRN).On 07/07/25 at 10:30 PM, an Administration Note documented R1 refused all medications but Buspar 30 MG and documented a notification to the charge nurse. On 07/08/25 at 10:19 PM, an Administration Note documented R1 refused all medications except Buspar and documented a notification to the charge nurse. On 07/09/25 at 09:43 AM, a Behavior Note documented R1 was heard yelling at and cursing at staff members this morning about not wanting to take his medications. R1 struck a door with no apparent injury to himself. Staff told R1 to take his medications, and then he could go out to smoke. R1 went inside, and when he went back out, he lied to staff about taking his medications to get a cigarette, as R1 still had not taken medications. On 07/09/25 at 09:56 AM, a Behavior Note documented the nurse heard a huge boom sound. When the nurse got up to investigate, R1 was coming back into the building after punching the outside patio door. The nurse asked the resident what the issue was, and R1 stated, I will talk to you about it in a minute after I get my meds. The note documented the nurse approached and informed the staff it was policy the resident be medication compliant before going out for a smoke break. The staff told the nurse R1 lied about taking his medications before he smoked. R1 then approached the nurse and asked if he could speak again. R1 was agitated and said he was not getting enough nicotine, and he needed extra smoke breaks or a nicotine patch. The nurse informed R1 that smoke breaks were at certain times, per facility policy. R1 asked about a nicotine patch and the nurse told R1 he would not be able to smoke with a nicotine patch. R1 became more agitated and said he wanted to beat up every nurse in the facility because they were all worthless. The nurse asked R1 if he would take his medications. R1 was still extremely agitated and said he would take Buspar, but he would not take any other medications because he was not schizophrenic. The note documented R1 then told the nurse to get his Buspar because the staff were making his anxiety high. A medication aide approached R1 to provide medication and R1 became rude and spiteful with the medication aide and said, Shut up and do your job, or you will get hurt. R1 picked out his Buspar and cursed at the medication aide. R1 walked away from the medication cart, swinging his fists in the air with a fast, long-stride pace in the hallway and gave evil looks at the other residents that were walking around him. The nurse also visualized R1 talking to unseen others and muttering under his breath. The nurse let R1 have some personal space for about 20 minutes and then went out to the patio and tried to educate the importance of taking his physician-prescribed medications. R1 then laughed sinisterly and stated again he was not mentally ill and only had an anxiety problem that everybody was making worse, and he just wanted to hurt people. The note documented R1, then walked off the patio into the facility, only to come into the office doorway. The note documented R1 wanted to apologize, and then his mood swung again to being rude and hateful. The staff offered an injection of anxiety medication, to help R1 relax, and he refused.On 07/09/25 at 09:54 PM, an Administration Note documented R1 refused all medications except Buspar, and documented notification to the charge nurse. On 07/09/25 at 11:11 PM, a Behavior Note documented R1 refused all medications except Buspar on the 02:00 PM to 10:00 PM shift, after three attempts to offer medications. The note documented notification to the physician. The EMR lacked evidence of follow-up after the physician notification. On 07/10/25 at 10:09 AM, a Behavior Note documented the nurse asked R1 if he wanted to switch to a different room, but R1 kept ignoring the nurse and walked away. When the nurse once again attempted to get R1's attention to ask, R1 told the nurse writer to shut up, not to talk, and just work. The note documented R1 further told the nurse that was what he paid them for, and then walked away.On 07/10/25 at 10:15 AM, a Behavior Note documented R1 was pacing in the hallway, talking to himself and other residents. The note documented R1 told others to wake up and made expletive remarks insulting their appearance. The note documented R1 made expletive remarks about staff, stated he was in charge and to watch those fingers or he would cut another one off, asking staff which one they wanted to lose.On 07/10/25 at 10:30 AM, a Behavior Note documented multiple staff members reported R1 was verbally aggressive towards them, calling them names, and using slurs.On 07/10/25 at 10:30 AM, a Nurse's Note documented speaking with the psychiatric provider about R1's behaviors and refusal of medications, and was awaiting further orders. The EMR lacked evidence of follow-up related to the note. On 07/10/25 at 11:06 AM, a Social Services Note documented the Social Worker made contact with R1's mother and Guardian and provided her with copies of the admission paperwork as requested. R1's mother expressed concerns about feeling pressured by a previous psychiatric hospital's Social Worker. The note documented R1's mother felt this other social worker rushed to discharge R1 and found placement prior to R1 being stabilized, especially since R1 had been non-compliant with his medications. R1's mother reported she dealt with R1's mental state and aggression since he was the age of 12 and reported feeling fearful of R1 due to his erratic behaviors. The note further documented R1's mother inquired about the steps that would need to be taken if R1 returned to the psychiatric hospital or was discharged from the facility. R1's mother reported R1 did not have access to a home he previously rented. R1's mother reported concerns about his substance use, concerns when R1 was unstable, and reported that R1 only agreed to come to the facility due to his ability to smoke cigarettes. On 07/10/25 at 03:45 PM, a Behavior Note documented R1 continued to have escalating behaviors and delusions throughout the shift. Staff were unable to redirect R1 as staff intervention caused further escalation of behaviors. R1 continued to be verbally abusive and intimidating towards staff, cursing and using slurs, threatening violence, and making delusional statements. On 07/10/25 at 03:58 PM, a Behavior Note documented R1 knocked on the door to the office of the Administrative Nurse D and Administrative Nurse E. The nurse answered the door, and the resident asked what they were doing. The nurse told the resident they were working. R1 asked why the staff were wasting his time. The nurse tried to close the door, and R1 pushed on the door trying to get in. The nurse got the door closed, and R1 started kicking the door multiple times, threatening bodily harm. After kicking stopped, the nurses opened the door and saw R1 down the hallway putting his middle finger up in the air. R1 cursed and said he wanted to get out of the facility, and if the staff did not let him out, he was going to kill everyone. The staff informed R1 he would have to sign out AMA if he wanted to leave. R1 told the staff to give him the paper. The staff returned his two packs of cigarettes and lighter. R1 signed AMA paperwork, and the staff let R1 leave.A Request for Discharge Against Medical Advice dated 07/10/25, recorded I hereby request to be discharged from the facility. I have been fully informed by my physician and the facility of the consequences of this action and understand that it is against my best medical interest to be discharged from the facility. I have further been fully informed by my physician, health care providers, and the facility of the risks inherent in the discharge from the facility against medical advice and they have explained the alternatives to me. After considering the alternatives, the risks involved, and the prognosis of my condition, I have requested that I be discharged from the facility, and I understand that it is against medical advice from my physician and the facility. The document further recorded Furthermore, my family members and next of kin have had an opportunity to discuss this matter with R1's provider and the representative of the facility and have been advised and are fully aware of the risks and dangers to my health if I am discharged from the facility. I understand the full import of this declaration and I am emotionally and mentally competent to make this declaration. The document was signed by R1 on 07/10/25. The document contained no other signatures. On 07/10/25 at 04:03 PM, a Nurse's Note documented R1 discharged AMA at 03:55 PM on 07/10/25 and was released from the facility. The staff notified R1's mother, psychiatric provider, and primary care provider. On 07/10/25 at 04:06 PM, a Social Service Note documented R1 left the facility against staff advice due to his altered mental status, delusional thoughts, hallucinations, refusing medications, and becoming increasingly more verbally aggressive. The Social Worker completed an Adult Protective Services (APS) report.On 07/10/25 at 04:15 PM a Communication - with Family, Next of Kin (NOK), Power of Attorney (POA) note documented staff spoke to R1's mother regarding R1 leaving the facility AMA. R1's mother understood R1 was being aggressive with staff, other residents, and chose to sign out against medical advice. R1's mother indicated this was R1's pattern. R1 stopped taking his medication and quickly became paranoid and aggressive. R1's mother also indicated she felt the previous psychiatric hospital discharged R1 before he was stable on his medication. The staff spoke to R1's mother about the facility's obligation to call APS and make a report that R1 was no longer at the facility, he signed out AMA and was having unmedicated mental health issues. R1's mother indicated she would come to the facility to pick up his property and his money within the next 30 days. The Social Worker notified APS. On 08/28/25 at 09:19 AM, R1's Representative stated she thought the facility called her to let her know R1 stopped taking his medications, but she was unsure if it was the day before R1 left AMA or the day he left. R1's Representative stated they told her R1 had not taken his medications for four days. R1's Representative stated her understanding was, for R1 to stay in the facility, he had to be medication compliant and thought he would be sent back to the state psychiatric hospital if he was not. R1's Representative stated the facility staff told her they would have a team meeting and would call her back, but she never heard back from them. R1's Representative stated that around 04:00 PM on 07/10/25, staff called to tell her R1 was no longer in the facility. R1's Representative stated she thought that meant R1 was sent back to the state hospital, but then staff told her R1 was let out of the building. R1's Representative stated she did not understand how this could happen at a locked facility, and she believed the facility let R1 go because R1 was too much trouble. She stated the facility did not call her to let her know about his behaviors or demanding to leave on 07/10/25. R1's Representative stated she did not understand how R1 could have signed himself out because she is R1's legal guardian. R1's Representative stated she spoke to the facility administrator and told her if R1 were to return to the facility, to call her. R1's Representative further stated she later found out R1 had returned to the facility the next day to pick up some cigarettes, but the facility did not contact her as requested. R1's Representative stated the administrator told her, after R1 had come and gone, that R1 came back to pick up his cigarettes the following day. R1's Representative stated the administrator told her she forgot to call when R1 came back. R1's Representative stated R1 was out in the community for about a week before the police picked him up and took him to a local hospital. She stated R1 was not from the area, did not know where he was, had no identification with him, and no phone. R1's Representative stated the police told her R1 was found walking down the middle of a freeway after he left AMA. The police told R1 he could not do that and was let go. She stated R1's second encounter with police was when R1 was kicked out of a bar after taking alcohol he could not pay for. R1's Representative stated the third time she was able to get a missing person report, the police found R1 and brought him to a local hospital. R1's Representative stated he was dehydrated and had a sunburn when he was picked up and taken to the hospital. R1's Representative stated she did not give permission for R1 to leave the facility and would not have given them permission to let him go AMA. R1's Representative stated there was no way R1 was ready to transition to the community, as he was not tracking well and was not compliant with his medications. On 08/27/25 at 01:49 PM, Administrative Staff A stated R1 was admitted to the facility from a psychiatric facility to stabilize on his medications. Administrative Staff A stated R1 took his medications initially, but started refusing to take them, became aggressive, and started hitting walls. Administrative Staff A stated R1 was being aggressive and stated he wanted out of the facility, so staff discussed the AMA paperwork with R1. Administrative Staff A stated staff attempted to explain to R1 that the doctor thought he needed to stay, but R1 wanted to leave, and staff could not hold him down. She stated R1 should have been taking his medications, but staff could not force him to take them. Administrative Staff A stated she believed staff contacted R1's guardian right after R1 left the facility and was unsure if anyone had contacted the guardian prior to R1 leaving AMA. Administrative Staff A stated that no one came to pick R1 up from the facility, he just left on his own. She reported R1 came back the next day to get his cigarettes but was not sure where he went after. She stated she was told R1 eventually ended up at a local hospital. Administrative Staff A stated staff told R1's guardian that R1 had refused his medications at one point during his stay, because the guardian went down to talk to R1 to get him to take them. Administrative Staff A further stated that beyond that one time, she was unable to recall if staff had updated the guardian of the refusals in the days prior to R1 leaving AMA. Administrative Staff A stated staff did not contact law enforcement when R1 wanted to leave AMA. On 08/28/25 at 10:25 AM, Administrative Nurse E stated he was at the facility the day R1 left AMA. Administrative Nurse E stated he could not remember how many days R1 was in the facility, but stated R1 was not compliant with taking his medications. Administrative Nurse E stated R1 tried to intimidate other residents and staff by cursing and calling them names. Administrative Nurse E stated R1 would refuse as-needed medications when offered and would become more agitated. Administrative Nurse E stated in the days leading up to 07/10/25, he was unsure if there were any new orders from the doctor when staff reported R1 was not taking his medications. Administrative Nurse E stated on 07/10/25, Administrative Nurse E was in a meeting with Administrative Nurse D, and R1 came to the door and asked what they were doing. Administrative Nurse E stated he told R1 they were working, and R1 became more agitated and threatened the staff. Administrative Nurse E stated he attempted to close the door, and R1 began kicking it several times. Administrative Nurse E stated when he opened the door up R1 was down the hall yelling that he wanted to leave the facility. Administrative Nurse E stated Administrative Staff A informed him he could sign out AMA. Administrative Nurse E said R1 did sign out AMA and was let out of the facility. He stated he was not sure if the guardian was contacted before or after, as he did not make those phone calls, but he was told the family was contacted. Administrative Nurse E stated the resident came back the next day to get his cigarettes, and the resident told him he slept outside behind a gas station. Administrative Nurse E stated staff went back inside, and when they came out again, R1 was walking down the street. Administrative Nurse E stated that if things were done by the book, then no, R1 should not have signed himself out due to having a guardian. Administrative Nurse E stated maybe the police should have been called, but R1 was so agitated all staff and residents were afraid of him. Administrative Nurse E stated when R1 signed out, there was no stopping him. Administrative Nurse E stated the staff probably should have called the guardian first.On 08/28/25 at 10:50 AM, Administrative Nurse D stated she was in the office the day R1 left AMA on 07/10/25. Administrative Nurse D stated R1 paced the halls and made threats to staff. Administrative Nurse D stated R1 continued to escalate and asked them, What are you going to do? Administrative Nurse D stated that Administrative Nurse E got up to shut the door, and R1 began kicking it repeatedly. Administrative Nurse D stated that when they finally came out of the room, R1 was down the hall talking to Administrative Staff A. She stated she could not hear all of the conversation, but wanted to stay away as Administrative Nurse E and herself were the targets of R1's aggression at that time, and she did not want to make it worse. Administrative Nurse D stated R1 was given AMA paperwork, signed out, and left the facility. Administrative Nurse D stated the guardian was called after R1 left the facility. Administrative Nurse D stated they were trying to make the environment safe first and then tried to follow the correct steps. Administrative Nurse D stated she knew staff had talked to the family prior, but it was not charted. Administrative Nurse D stated the guardian was not upset that day when they made contact, and R1 came back the next day. Administrative Nurse D stated she knows the policy, and if a resident has a guardian, and the guardian says the resident cannot leave, then they have to deal with them. Administrative Nurse D stated if a resident had a guardian, they had to notify them before they are allowed to leave. Administrative Nurse D stated looking back, the policy was not followed. Administrative Nurse D stated she had never been that scared, and at some point, they have to protect the other residents and staff. Administrative Nurse D stated when staff contacted the physician about R1 not taking his medications, she believed the provider had not seen R1 yet, and the response was to continue to encourage R1 to take his medications. Administrative Nurse D stated they could have contacted law enforcement when R1 became aggressive, but they did not have a good history with the local police department, they often took a long time to show up, and had a history of not doing anything. Administrative Nurse D stated that it all happened so fast, but they should have called the police. On 08/28/25 at 11:00 AM, Administrative Staff A stated on 07/10/25, R1 was aggressive, threatening staff, and kicking the door. Administrative Staff A stated R1 was yelling that he wanted out and they could not keep him at the facility. Administrative Staff A stated she knew R1 had a guardian, but if R1 refused to stay, she would have the nurse read the AMA document to R1, explain it, and let him sign out. Administrative Staff A stated after R1 signed, they let him out the door. Administrative Staff A stated they called the guardian, the provider, and made a report to APS after R1 left AMA. Administrative Staff A stated R1 came back the next morning to pick up his cigarettes. Administrative Staff A stated she told R1's guardian he said he would be back the next day, and the guardian just said Okay. Administrative Staff A stated the guardian did not ask Administrative Staff A to call her the next day if R1 came back to the facility. Administrative Staff A stated the guardian understood the resident was being aggressive, and the guardian said R1 had been that way for a while. Administrative Staff A stated they have called the police at times when residents became aggressive, but because of the mental illness, the police just talk to them and leave. She stated the police would not take them away, and they could not press charges. Administrative Staff A stated she was not aware they needed to contact the guardian first before a resident left AMA. Administrative Staff A stated she knew they had to contact the guardian if they left, she just did not know it had to be before the person left. She stated based on the wording in R1's guardianship papers, R1 should not have been able to sign himself out. The facility's undated Transfer and Discharge (Including AMA) policy, documented AMA only applied when a resident expressed their wishes to be discharged earlier than outlined in the care plan. These situations did not apply if the facility offered to discharge a resident to a location that did not meet their health and or safety needs, and the resident agreed. The resident and family/legal representative should be informed of the risks involved, the benefits of staying at the facility, and the alternative to both. Under no circumstances would the facility force, pressure, or intimidate a resident into leaving AMA. The physician should be notified of the intended AMA discharge and be encouraged to speak with the resident to encourage them to stay at the facility. Documentation of this notification should be entered in the nurse's notes by the nursing department. The social services designee should document any discussion held with the resident/family in the social service program notes, if present, notify Adult Protective Services (APS), or other entity as appropriate, if self-neglect is suspected, and document accordingly. On 08/28/25 at 03:15 PM, Administrative Staff A was provided the IJ template and notified the facility's failure to provide adequate and appropriate services, including physician and guardian involvement to treat a behavioral health crisis, placed R1 in immediate jeopardy.The facility submitted an acceptable IJ removal plan on 08/28/25, which included the following: 1. Administrative Nurse D re-educated staff that administered medication on facility Notification of Changes policy to include notification to physician and guardian/responsible party upon refusal of medications.2. The facility began an audit process for refusal of medications for appropriate notifications to the physician and guardian/responsible party daily for 4 weeks, starting on 08/28/25.3. The Regional Nurse Consultant re-educated IDT and professional nursing staff on facility Transfer and Discharge policy including Against Medical Advice Process.4. The Regional [NAME] President and/or Regional Nurse Consultant would be notified prior to any resident leaving Against Medical Advice to ensure facility processes were followed, starting 08/28/25.On 08/28/25 at 04:41 PM, the surveyor verified the above corrective actions were implemented. The scope and severity remained at G to reflect the serious adverse outcome, including dehydration and exposure.