Tucker Operating Company: Accident Hazard Failures - GA
The facility owner found the resident at 10:15 pm on October 1st after driving around the area. Staff at Tucker Operating Company had been looking for him since 8:40 pm, but concentrated their search indoors because they believed he was unable to walk.
The administrator attempted to call law enforcement but hung up after being on hold for 40 minutes without filing a police report.
The resident's family had never been asked about wandering tendencies during admission, despite his history of attempting to leave the hospital against medical advice. His daughter, serving as his representative, said facility staff initially told her police had been notified when they called between 7:00 and 8:00 pm to report her father missing.
Staff later called back claiming they had found him inside the building and that he never left the facility. This contradicted what actually happened.
A certified nursing assistant working that evening recalled seeing the resident at 7:00 pm when the morning shift was leaving. She asked other staff if he was a visitor, and they confirmed he was a resident. When she asked if he needed anything, he said he was okay.
At 8:40 pm, the same nursing assistant checked his room and couldn't find him. She informed a nurse and another nursing assistant, and they began searching. She went outside and looked through nearby apartments before returning to the facility after 10:00 pm, when she learned he had been located.
The facility had never conducted elopement drills or training before this incident. A nursing assistant working on the rehabilitation unit said she had received no training regarding elopement drills. The facility only began discussing elopement training on October 2nd, the day after the incident.
A registered nurse explained that required protocols weren't followed when the alarm sounded. No head count was completed, and staff failed to do rounds to ensure all residents were accounted for.
The administrator was the only person with access to review security camera footage, but she didn't check the cameras because she was "too busy."
The social services director visited the resident the night after he went missing. She found that he couldn't recall leaving the facility and was unaware of the date and time. His family requested his transfer following the incident.
Staff had failed to review the resident's history and physical documentation before his admission, which would have revealed his exit-seeking behaviors. The administrator acknowledged that "mistakes were made" and said the facility was unaware of his wandering tendencies.
No elopement assessment was completed at admission, despite this being a required procedure. The facility only placed a wander guard on the resident and began conducting training after the incident occurred.
The administrator chose not to notify the state about the incident because the resident wasn't harmed. However, the resident had spent over two hours sitting alone on a roadside at night, a quarter mile from the facility, while staff searched in the wrong location.
The corporate owner happened to be in the area when the administrator reported the resident missing. He drove around the facility grounds and found the resident sitting on the curbside. The owner was unaware whether law enforcement had been notified about the missing resident.
The facility's response revealed multiple system failures: no elopement training, no security camera review, inadequate admission assessments, and staff who didn't understand basic protocols for missing residents. The resident's daughter said her father had previously tried to leave a hospital against medical advice, information that should have triggered immediate safety precautions.
The resident sat alone on a dark roadside for more than two hours while his family believed police were searching and staff insisted he never left the building.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Tucker Operating Company LLC from 2025-11-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
TUCKER OPERATING COMPANY LLC in TUCKER, GA was cited for violations during a health inspection on November 20, 2025.
The facility owner found the resident at 10:15 pm on October 1st after driving around the area.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.