The resident, identified in inspection records as R1, woke up one morning to find her wedding ring gone from her left hand. The ring finger showed a visible indentation where the jewelry had been worn, with lighter-colored skin marking its absence.
"It was a tight-fitting ring and just wouldn't slide off," R1 told inspectors during their November 24 visit. "I never took the ring off."
The missing ring was substantial. R1 described it as large, stretching from her knuckle to the base of her finger, made of yellow gold and set with numerous diamonds including two large stones. "I miss it a lot," she said.
R1's roommate and another resident who regularly sat with her at meals confirmed she always wore the ring. Both witnessed R1's distress when she announced the theft at breakfast one morning.
"R1 came to breakfast one day and told myself and R3 that the ring was missing," the roommate told inspectors.
Multiple staff members knew about the missing ring but failed to report it up the chain of command as required by facility policy.
The housekeeping manager was among the first to learn of the theft. She found R1 in her room one morning, visibly upset about the missing jewelry.
"She was very upset about it," the housekeeping manager told inspectors. She immediately began searching, looking under R1's bed, in her wheelchair, and shaking out her pajama pants. She instructed another housekeeper to strip R1's bed when the resident went to breakfast and search through the covers.
But the housekeeping manager admitted she never reported the missing ring to administrators. "She did not report R1's missing ring to anyone, but she should have," according to the inspection report.
A certified nursing assistant also learned of the theft when R1 was housed on the south hallway. The CNA said she told the nurse on duty at the time and discussed it with another nursing assistant, but the missing ring never reached facility leadership.
The administrator only discovered the theft on November 17 when R1's nephew, who serves as her power of attorney, came to the facility and reported it directly.
This represented a clear violation of Pearl Pavilion's own Abuse Prevention Program Policy, dated January 2024. The policy explicitly 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 or to an immediate supervisor who must then immediately report it to the administrator."
The administrator confirmed that staff are required to report missing resident items "right away to the administrator of supervisor according to their abuse policy."
Instead, multiple staff members spent an undetermined period helping R1 search for the ring while keeping the theft from facility leadership. The housekeeping manager organized searches of R1's room and bedding. Nursing assistants discussed the missing jewelry among themselves. But none followed the mandatory reporting protocol designed to trigger a formal investigation.
The failure to report the missing ring meant no official investigation was launched to determine how the valuable jewelry disappeared from R1's finger while she slept. No incident report was filed. No review of who had access to R1's room was conducted. No examination of whether other residents had experienced similar thefts took place.
The ring's description suggests significant monetary value. Wedding rings featuring multiple diamonds, particularly those with two large stones set in gold, typically represent substantial investments. For elderly residents, such jewelry often carries deep sentimental value in addition to its financial worth.
R1's physical description of the ring's tight fit raises questions about how it could have been removed without her knowledge. The visible indentation and color difference on her finger indicated long-term wear of a snug-fitting band that would not easily slip off during sleep or routine care.
The inspection identified this as a complaint-driven survey, suggesting family members or other concerned parties contacted state regulators about conditions at Pearl Pavilion. The administrator's admission that she only learned of the missing ring when R1's nephew reported it directly indicates family frustration with the facility's handling of the situation.
Federal regulations require nursing homes to protect residents' personal property and investigate any suspected theft immediately. The failure to report missing valuable items prevents facilities from conducting timely investigations when evidence and witness memories are fresh.
Pearl Pavilion's policy clearly established the reporting requirements that staff ignored. The January 2024 date on the abuse prevention policy indicates recent updates to these procedures, making staff unfamiliarity an unlikely excuse for the reporting failure.
The inspection found this violation affected few residents, but the case illustrates systemic problems with staff training and policy compliance. Multiple employees across different departments knew about the theft but failed to follow mandatory reporting procedures.
R1 continues to live at Pearl Pavilion without her wedding ring. The valuable jewelry remains missing, and the delayed reporting likely compromised any investigation into its disappearance. The resident who described missing her ring "a lot" must cope with both the loss of her treasured jewelry and the knowledge that staff she trusted failed to follow basic protocols designed to protect her property.
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.