POPA GOOD SAMARITAN SERVICES, LLC.

PRINTED: 04/22/2026 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION {X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED & 30440 BR i iets 04/09/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 169793 HWY 39 POPA GOOD SAMARITAN SERVICES, LLC VERONA, MO 65769 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES iD PROVIDER'S PLAN OF CORRECTION (x5) PREFIX | (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG | REGULATORY OR LSC IDENTIFYING INFORMATION} TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A4724, 19 CSR 30-86.047(19) TB Screen Residents & A4724 | Staff The facility shall screen residents and staff for tuberculosis as required for long-term care - facilities by 19 CSR 20-20.100. 1! This regulation is not met as evidenced by: Based on interview and record review, the facility failed to screen staff for tuberculosis (TB - a _ communicable disease that affects the lungs | characterized by fever, cough, and difficulty in | breathing) as required when staff failed to | compiete the annual screening test timely after | hire for three staff members (Owner/Level One | Medication Aide (LIMA) A, LIMA B, and LIMA C). _ The facility census was seven. Review of the facility's Tuberculosis Policy, updated 06/30/24, showed the following: -All employees previously TB skin test negative will submit to periodic retesting will be retested at least annually and employees who are _ occupationally exposed to a patient/resident with infectious TB will resubmit to testing as directed by the facility nurse; -All employees with a documented history of a | positive TB skin test, or adequate treatment for | active TB, or previous therapy for latent TB | infection, shall be exempt from further TB skin testing. All employees will be required to submit an annual TB statement. , General requirements for Tuberculosis Testing for Residents and Staff in Long Term Care Facilities, 19 CSR 20-20.100, reads as follows: , ~All new long term care facility employees and | volunteers who work ten or more hours per week | are required to obtain a Mantoux PPD (TB skin | test) two-step tuberculin test within one month | prior to MissouriDepartment of Health and Senior Services ATURE TITLE (X6) DATE STATE FOR ome BSF911 if continuation sheet 1 of 4 PRINTED: 04/22/2026 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED ie 30440 B. WING 04/09/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 16979 HWY 39 VERONA, MO 65769 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) POPA GOOD SAMARITAN SERVICES, LLC Continued From page 1 starting employment in the facility; -lf the initial test is zero to nine millimeters, the second test should be given as soon as possible within three weeks after employment begins, unless documentation is provided indicating a Mantoux PPD test in the past and at least one subsequent annual test within the past two years; -It is the responsibility of each facility to maintain a documentation of each employee's and volunteer's tuberculin status; -Employees and volunteers with an initial zero to nine millimeters (mm) Mantoux PPD two-step test shall be one-step tuberculin tested annually and the results recorded in a permanent record; -All positive findings shall require a chest X ray to rule out active pulmonary disease; -Individuals with a positive finding need not have repeat annual chest X rays. They shall have a documented annual evaluation to rule out signs and symptoms of tuberculosis disease. 1. Review of Owner/LIMAA's personnel record showed the following: -Hire and start date of 02/21/17; -Last documented an annual TB screening/chest x-ray on 03/07/24 (over a year prior). 2. Review of LIMA B's personnel record showed the following: -Hire and start date of 01/31/17; -Last documented an annual TB screening test on 03/07/24 (over a year prior). 3. Review of LIMA C's personnel record showed the following: -Hire and start date of 01/01/19; -Last documented an annual TB screening test on 03/15/24 (over a year prior). Missouri Department of Health and Senior Services STATE FORM 6899 BSF911 If continuation sheet 2 of 4 PRINTED: 04/22/2026 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED ie 30440 B. WING 04/09/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 16979 HWY 39 VERONA, MO 65769 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) POPA GOOD SAMARITAN SERVICES, LLC Continued From page 2 4. During an interview on 04/09/26, at 12:55 P.M., the Owner/LIMAA said the following: -The Administrator is responsible for completing the annual TB screening for employees; -He/She thought the Administrator completed the annual screening for the year. 19 CSR 30-86.047(28)(F)(1)(B) Community Based Assessment - Semi-Annually The facility may admit or retain an individual for residency in an assisted living facility only if the individual does not require hospitalization or skilled nursing placement as defined in this rule, and only if the facility: (F) Completes a community based assessment conducted by an appropriately trained and qualified individual as defined in section (4) of this rule: 1. Time frame requirements for assessment shall be: B. At least semiannually; II This regulation is not met as evidenced by: Based on interview and record review, the facility staff failed to complete a community-based assessment (CBA-determines an individual's specific needs for care and support before admission and periodically after) at least semiannually for two of three sampled residents (Resident #1 and Resident #2). The facility census was seven. Review showed the facility did not provide a policy regarding completion of CBAs. 1. Review of Resident #1's face sheet (basic medical information) showed the following: -Admission date of 01/03/17; Missouri Department of Health and Senior Services STATE FORM 6899 BSF911 If continuation sheet 3 of 4 PRINTED: 04/22/2026 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED ie 30440 B. WING 04/09/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 16979 HWY 39 VERONA, MO 65769 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) POPA GOOD SAMARITAN SERVICES, LLC Continued From page 3 -Diagnoses included degenerative brain disease (an incurable, progressive condition marked by the decline and death of neurons in the brain or spinal cord, leading to worsening mental or physical function) and depression. Review of the resident's medical record showed staff did not document a completed CBA since 08/09/25 (two months overdue). 2. Review of Resident #2's face sheet showed the following: -Admission date of 07/05/23; -Diagnoses included atrial fibrillation (a-fib - type of irregular heart rhythm characterized by rapid, chaotic electrical signals causing the heart's upper chambers to quiver instead of contracting properly), anxiety, and depression. Review of the resident's medical record showed staff did not document a completed CBA since 07/01/25 (three months overdue). 3. During an interview on 04/09/26, at 12:55 P.M., Owner/Level One Medication Aide (LIMA) A said the following: -He/She is certified to complete resident CBA's and is responsible for completing these assessments in the facility; -The resident's CBA needs to be updated every six months, but he/she did not update the assessments in a timely manner. Missouri Department of Health and Senior Services STATE FORM 6899 BSF911 If continuation sheet 4 of 4 PLAN OF CORRECTION Provider/Supplier Name: Popa Good Samaritan Assisted Living 1 Street Address, City, Zip: Date of Survey: 4/9/26 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 30440 16979 Hwy 39 Verona, MO 65769 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: {EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE | Popa Good Samaritan Assisted Living is committed to providing exceptional care and services to our residents. Any deficiencies noted through the survey process (extemal or internal), is promptly corrected with diligence and efficacy. This Plan of Correction (POG) is submitted as required under State Law. The submission of the POC does nat constitute an admission on the part of Popa Good Samaritan Assisted Living ("the facility”) as to the accuracy of the surveyor findings, nor the conclusions drawn there from. The facility’s submission of the POC does not constitute an admission regarding the deficiencies cited are correctly applied. This POC is intended to constitute the Facility’s credible letter alleging compliance. Compliance has been and will be achieved no later than the last completion date identified in the POC. Compliance will be maintained as provided in the Plan of Correction. The facility does and will continue to ensure that Employees The action complete a TB screening form upon hire and annually. pian will be A4724 implemented prior to or by | 5/4/26 Corrective action wiil be accomplished for the residents found to be affected by the alleged deficient p ractice by: A. The 3 identified staff members have completed TB Screening in accordance with facility policy requiring Screening upon hire and annually thereafter. Documentation has been verified and filed in each ____ employee health record. The facility identifies ail residents as potentially affected by this alleged deficient practice. The corrective action will be accomplished by: A. An audit of 100% of employee health files was conducted to ensure compliance with facility policy requiring TB screening at hire and annually. The measures put in place and systemic changes were made to ensure that alleged deficient practice does not recur: A. The Administrator re-educated the Owner on the policy requiring TB screening prior to or within the timeframe outlined at hire and annually thereafter. B. The facility implemented a tracking log consistent with policy requirements to monitor TB screening due dates. C. Annual TB screening due dates are now tracked using a calendar reminder system to ensure ongoing compliance. The facility plans to monitor its performance to make sure that solutions are achieved and sustained. This plan will be implemented, and the corrective action will be evaluated for its effectiveness. A. The Administrator or designee will audit 10% of employee health records weekly for 4 weeks, then monthly for 2 months, to ensure TB screening is completed The Administrator signing and dating the first page of the CMS-2567/State Form is indicating their approval of the plan of correction being submitted on this form. Provider/Supplier Name: Street Address, City, Zip: PLAN OF CORRECTION Popa Good Samaritan Assisted Living 16979 Hwy 39 Verona, MO 65769 | Date of Survey: ID PREFIX TAG 4/9/26 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 30440 PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} DATE A4750 Popa Good Samaritan Assisted Living is committed to providing exceptional care and services to our residents. Any deficiencies noted through the survey process (external or internal), is promptly corrected with diligence and efficacy. This Plan of Correction (POC) is submitted as required under State Law. The submission of the POC does not constitute an admission on the part of Popa Good Samaritan Assisted Living | (“the facility”) as to the accuracy of the surveyor findings, nor the conclusions drawn there from. The facility's submission of the POC does not constitute an admission regarding the deficiencies cited are correctly applied. This POC is intended to constitute the Facility's credible fetter alleging compliance. Compliance has been and will be achieved no later than the last completion date identified in the POC. Compliance will be maintained as provided in the Plan of Correction. The facility does and will continue to ensure that Resident The action community-based assessments are completed semi-annually plan will be and with a significant change. implemented prior to or by 5/4/26 Corrective action will be accomplished for the residents found to be affected by the alleged deficient practice by: A. The 2 identified residents have had their community- based assessments completed to reflect current needs, preferences, and level of care. Assessments have been reviewed for accuracy and updated in the resident records. The facility identifies all residents as potentially affected by this alleged deficient practice. The corrective action will be accomplished by: A. A100% audit of all current resident records was conducted to ensure community-based assessments are completed at least semiannually and are current. The measures put in place and systemic changes were made to ensure that alleged deficient practice does not recur: A. The owner, (who is responsible for assessments) were re-educated on the requirement that community- based assessments must be completed at least every six (6) months and with any significant change in _ condition B. Assessment due dates are now entered into a calendar reminder system to ensure timely completion C. The facility implemented a tracking system to monitor due dates for all resident assessments The facility plans to monitor its performance to make sure that solutions are achieved and sustained. This plan will be implemented, and the corrective action will be evaluated for | its effectiveness. A. The owner will audit 100% of resident assessments weekly for 4 weeks, then audit 50% of resident records monthly for 2 months to ensure semi-annual assessment requirements. _ The Administrator signing and dating the first page of the CMS-2567/State Form is indicating their approval of the plan of correction being submitted on this form.

PRINTED: 06/24/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 30440 CNN ae pe pea ae as 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 16979 HWY 39 VERONA, MO 65769 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION PREFIX | (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) POPA GOOD SAMARITAN SERVICES, LLC 19 CSR 30-86.047(19) TB Screen Residents & Staff The facility shall screen residents and staff for tuberculosis as required for long-term care facilities by 19 CSR 20-20.100. II This regulation is not met as evidenced by: Based on interview and record review, the facility failed to screen residents as required when staff failed to complete the required two step tuberculosis (TB - a communicable disease that affects the lungs characterized by fever, cough, and difficulty in breathing) screening test timely for one resident (Resident #1) and failed to complete a required annual screening timely for one resident (Resident #2). The facility census was 7. General requirements for Tuberculosis Testing for Employees and Residents in Long Term Care Facilities, 19 CSR 20-20.100, reads as fallows: -Long-term care facilities shall screen their residents using the Mantoux method PPD five | tuberculin unit test (TST - skin test). Each facility | shall be responsible for ensuring that all test | results are completed and that documentation is maintained; | -Within one month prior to or one week after admission, all residents new to long-term care are required to have the initial test of a two-step TB test; -If the initial test is negative, the second test should be given as soon as possible within three weeks; -All long-term care facility residents shall! have a | documented annual evaluation to rule out signs and symptoms of tuberculosis disease. Review showed the facility did not provide a Missouri Department of Health and Senior Services ; LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DA ‘ ? i gf = £ (AS UIGEDS HOMAS/2 Ys ay STATE FORM a ae) WON911 If continuation sheet 1 of 2 PRINTED: 06/24/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 30440 B. WING 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 16979 HWY 39 VERONA, MO 65769 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) POPA GOOD SAMARITAN SERVICES, LLC Continued From page 1 policy regarding resident TB testing. 1. Review of Resident #1's medical record showed the following: -Admission date of 09/27/22: -Diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), and rheumatoid arthritis (a chronic inflammatory disorder usually affecting small joints in the hands and feet); -Staff documented the first step TB screening test administered on 02/24/23 and read on 02/26/23 (five months after admission) with a negative result; -Staff did not document the second TB screening test was administered. 2. Review of Resident #2's medical record showed the following: -Admission date of 01/03/17; -Diagnoses included dementia (a group of thinking and social symptoms that interferes with daily functioning), and depression; -Staff last documented an annual TB screening on 02/21/23. 3. During an interview on 06/13/24, at 12:30 P.M. the Owner said the following: -He/She and the Administrator are responsible for resident TB testing; -He/She did not know that Resident #1's TB test was late and the second step not administered; -He/She did not know Resident #2 was behind on the annual TB screening. Missouri Department of Health and Senior Services STATE FORM 6899 WONQ11 If continuation sheet 2 of 2 PLAN OF CORRECTION Provider/Supplier Popa Good Samaritan Assisted Living Name: Street Address, City, Zip: 16979 Hwy 39 Verona, MO 65769 6/13/24 Date of Survey: 30440 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE Popa Good Samaritan Assisted Living is committed to providing exceptional care and services to our residents. Any deficiencies noted through the survey process (external or internal), is promptly corrected with diligence and efficacy. This Plan of Correction (POC) is submitted as required under State Law. The submission of the POC does not constitute an admission on the part of Popa Good Samaritan Assisted Living (‘the facility”) as to the accuracy of the surveyor findings, nor the conclusions drawn there from. The facility's submission of the POC does not constitute an admission regarding the deficiencies cited are correctly applied. This POC is intended to constitute the Facility’s credible letter alleging compliance. Compliance has been and will be achieved no later than the last completion date identified in the POC. Compliance will be maintained as provided in the Plan of Correction. The facility does and will continue to ensure that all Residents The action and staff will obtain a 2 step PPD upon admission/hire and all plan will be Residents receive a yearly TB screening every year thereafter. implemented prior to or by 6/30/24 Corrective action will be accomplished for the residents found to be affected by the alleged deficient practice by: A. Resident #1 was given #1 of PPD 2 step on 6/13/24, TB test was read on 6/15/24 with negative results. #2 of PPD 2 step was given on 6/22/24 and read on 6/24/24 with negative results. . Resident #2 annual TB Screening was performed on 6/13/24. The facility identifies all residents as potentially affected by this alleged deficient practice. The corrective action will be accomplished by: A. Administrator did not identify any additional residents with any outcome from the alleged deficient practice. deel rteoms Administrator. bag lal The measures put in place and systemic changes were made to ensure that alleged deficient practice does not recur: A. Administrator ensured that all Residents annual TB screenings were up to date. B. Administrator in-service staff regarding TB regulations for long-term care on 6/13/24. C. Administrator will update TB testing policy by 6/30/24. The facility plans to monitor its performance to make sure that solutions are achieved and sustained. This plan will be implemented, and the corrective action will be evaluated for its effectiveness. A. Administrator will audit all Residents charts upon admission and yearly for up-to-date documentation. The Administrator signing and dating the first page of the CMS-2567/State Form is indicating their approval of the plan of correction being submitted on this form.

Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 16979 HWY 39 POPA GOOD SAMARITAN SERVICES, LLC VERONA, MO 65769 PRINTED: 01/30/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 01/10/2024 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE A3214 19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected In facilities that are constructed or have plans approved after July 1, 2005, electrical wiring shall be installed and maintained in accordance with the requirements of the National Electrical Code, 1999 edition, National Fire Protection Association, Inc., incorporated by reference, in this rule and available by mail at One Batterymarch Park, Quincy, MA 02269, and local codes. This rule does not incorporate any subsequent amendments or additions to the materials incorporated by reference. Facilities built between September 28, 1979 and July 1, 2005 shall be maintained in accordance with the requirements of the National Electrical Code, which was in effect at the time of the original plan approval and local codes. This rule does not incorporate any subsequent amendments or additions. In facilities built prior to September 28, 1979, electrical wiring shall be maintained in good repair and shall not present a safety hazard. All facilities shall have wiring inspected every two (2) years by a qualified electrician. II/IIl This regulation is not met as evidenced by: Class III Based on document review and interview on January 10, 2024, the facility failed to ensure the facility's electric wiring was inspected every two (2) years by a qualified electrician. The facility census on January 10, 2024, was eight (8). This deficiency affects eight (8) of eight (8) residents. Document review showed the last electrical wiring inspection by a qualified electrician was completed on November 12, 2021. During an interview on January 10, 2024, at 12:45 Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE STATE FORM 6899 WRMV11 DEFICIENCY) (X6) DATE If continuation sheet 1 of 2 PRINTED: 01/30/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 16979 HWY 39 VERONA, MO 65769 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) POPA GOOD SAMARITAN SERVICES, LLC A3214 | Continued From page 1 P.M., the owner said he/she was unaware that the electrical inspection was due, but immediately called an electrician and scheduled the inspection. Missouri Department of Health and Senior Services STATE FORM 6899 WRMV11 If continuation sheet 2 of 2 THE FACILITY DID NOT RETURN A PLAN OF CORRECTION THEREFORE, NO POC IS INCLUDED WITH THE STATEMENT OF DEFICIENCIES (2567 FORM)