The resident woke up one morning to find her wedding ring gone from her left hand, which still showed a visible indentation and lighter skin where the tight-fitting band had been worn. She told inspectors she never took the ring off and was very upset when she discovered it missing.
"It was a large ring and went from my knuckle to the base of my finger," the resident said during the November 24 inspection. "It had numerous diamonds with two large diamonds and it was yellow gold. I miss it a lot."
The ring fit so snugly that it wouldn't slide off, according to the resident and witnesses who saw her wear it daily at meals. Her roommate and another resident confirmed she always had the ring on and told them at breakfast one morning that it was missing.
But despite federal requirements that nursing homes immediately report suspected theft of resident property, staff members who learned about the missing ring failed to notify administrators for days.
The housekeeping manager said the resident told her about the missing ring one morning and was very upset. She searched under the bed, in the wheelchair, and shook out pajama pants. She instructed another housekeeper to strip the bed and look in the covers when the resident went to breakfast.
"She did not report the missing ring to anyone, but she should have," according to the inspection report.
Two nursing assistants also knew about the missing jewelry. One said the resident told her about the ring "awhile back" when she was living in a room on the south hallway. The nursing assistant said she told the nurse on duty and discussed it with another aide.
She found the resident upset with belongings scattered on the floor while searching for the ring. The aide helped look and put the resident's things back in order.
The second nursing assistant confirmed hearing about the missing ring at breakfast one morning and said her colleague had reported it.
The administrator only learned about the missing ring on November 17 when the resident's power of attorney and nephew came to the facility and reported it directly to her. By then, the resident had already been moved from the south hallway room where the ring disappeared to a different room on November 11.
The delay violated the facility's own abuse prevention policy, which requires employees to report "any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about or suspect to the administrator immediately."
Federal regulations mandate the same immediate reporting requirements for suspected theft of resident property.
The resident had lived in the south hallway room from her admission date until November 11, when she was transferred to her current room. Multiple staff members and residents confirmed the ring's disappearance occurred while she was in the original room.
The roommate who ate meals with the missing ring's owner said she and another resident regularly sat with her and always saw the ring. Both confirmed the resident came to breakfast one morning and announced the jewelry was gone.
The housekeeping manager's search efforts included enlisting other staff to help look through bedding and personal items, but the systematic search failed to locate the valuable ring.
The resident's distress over the loss was evident to multiple staff members and fellow residents. She was described as "very upset" by both the housekeeping manager and nursing assistant who witnessed her reaction to discovering the theft.
The nursing assistant who helped reorganize the resident's belongings found her in significant emotional distress, with personal items strewn across the floor during her desperate search for the missing ring.
Despite the resident's clear attachment to the jewelry and the obvious signs it had been worn continuously, the failure to immediately report the suspected theft meant administrators couldn't begin an investigation or notify proper authorities as required.
The administrator told inspectors that staff are supposed to report missing resident items "right away" to either the administrator or a supervisor, who must then immediately report to the administrator.
The violation affected one of three residents reviewed for theft in a sample of five residents examined during the inspection. Federal inspectors found minimal harm or potential for actual harm to few residents.
The resident's nephew and power of attorney ultimately had to bring the missing ring to the administrator's attention themselves, nearly a week after staff members first learned about the disappearance.
The case highlights how communication breakdowns can prevent nursing homes from properly investigating and reporting suspected crimes against vulnerable residents, even when multiple staff members are aware of the incidents.
The resident continues to show physical evidence of wearing the ring for years, with the permanent indentation and color difference on her finger serving as a constant reminder of her loss.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pearl Pavilion from 2025-11-24 including all violations, facility responses, and corrective action plans.