PHOENIX (KSAZ) - When a person places their loved one in assisted living or a nursing home, they would hope that everyone working there will make sure they're safe, healthy and happy. One valley man thought he put his mother in the perfect place.
Until she ended up in the hospital three times, in as many months. No one could figure out what was wrong with the man's mother until they started looking into her pill bottles.
A year ago, the woman, identified as "Dolores", was near death, lying in a hospital bed, and kept alive by machines. Her son, Gary Paris, said until that day, she was a healthy 83 year old.
Then, all of a sudden, everything changed.
"Basically, they were preparing me for her to pass away," said Paris. "They pretty much said, 'we can't figure out what's causing these problems. We think shes given up.'"
Paris and his parents spent a year searching for the perfect assisted living facility, and ended up choosing "Montecito Senior Living" in Peoria. The facility's website shows beautiful grounds, swimming pools, well appointed rooms, dining halls, even a theater.
Paris' mother and father had planned to move in together.
"Three days before he was supposed to move in, he passed away," said Paris.
Dolores moved in, alone, in April of 2016, paying $6,000 dollars a month for a beautiful room and limited nursing care. Montecito's website promised, "all of the attention and peace of mind you desire", but it didn't quite work out that way.
Six months into her stay, Dolores unexpectedly got very sick. She was rushed to the hospital, in organ failure and bleeding from the rectum.
"They were just saying, 'your mother is very, very sick',' said Paris. "She was getting worse, and they couldn't figure out what was creating the problems."
Over the next two months, Dolores was rushed to the hospital three times. Then, Dolores' son got a shocking phone call. Montecito's management was about to unravel the medical mystery by officially finding that there's a medtech that was allegedly stealing Paris' mother's Tramadol, and replacing it with another medication.
Dolores' pain pills, Tramadol, were replaced with hydroxycloryquine, commonly known as Plaquenil. Plaquenil is a powerful drug that is used to treat malaria.
"If someone is having Plaquenil substituted for Tramadol, they're probably getting extraordinarily high and frequent dose of Plaquenil," said Dr. Michel Scuher, CMO for Community Bridges.
It could be fatal, and it nearly was.
"The PA called me and said, 'your mother is bleeding really bad, and we've got emergency coming to take her back again,'" recounted Paris.
Dolores spent nine days in intensive care. Paris was told his mom wouldn't make it through the weekend.
"Basically, they were preparing me for her to pass away," said Paris.
Side by side, Tramadol and Plaquenil tablets look nearly identical, but it was not an innocent mistake.
"I call it being poisoned," said Paris.
As it turns out, three other Montecito residents had their medications switched. Suspicions quickly turned to a 40-year-old caregiver named Saada Omer. Omer happens to be from Somalia, which is a hotbed for malaria, and a place where Plaquenil is in abundant supply.
Peoria police interviewed the Montecito staff, and Omer was reportedly the only one unavailable for the meeting. Med-techs were asked who did this, and Omer was reportedly "the most likely possibility".
Omer had also been fired from another care home for "medication discrepancies". Police also discovered Omer had obtained 11 prescriptions from five doctors for Tramadol, which is the same drug stolen at Montecito.
"She was very kind, and one of my moms favorite people there," said Paris. "She's a very, very good actress, and she's getting what she wants."
Montecito fired Omer. According to a Peoria Police report, Omer allegedly "committed aggravated assault, abuse of a vulnerable adult, endangerment and theft...by stealing prescription pain medication and replacing it with an anti-malaria medication."
Police, however, didn't have an eyewitness or security video showing Omer stealing the medication. So, the case was dropped, without police ever interviewing Omer.
"I don't know why she hasn't been arrested. I don't know why she hasn't been convicted, and I don't know why Montecito hasn't tracked down everyone and said, 'you cant have this woman doing this at your facility. This is what she did at our facility,'" said Paris. "That just blows me away."
Omer could still be working as a caregiver, and she has hired an attorney who tells FOX 10 Phoenix that she will not discuss the matter with FOX 10 Phoenix.
Ultimately, however, Montecito is responsible for what happened to Dolores, and they are being sued for failing to protect her.
"I don't think the facility had proper controls and check and balances in place," said John Balitis, an attorney representing the family. "Why didn't management know that? The victims are elderly and vulnerable."
Officials with Montecito told FOX 10 Phoenix it will not comment on an on-going lawsuit.
As for Dolores, she chose to return to Montecito following her terrible ordeal.
"Last thing she wants to do where she's at, she's comfortable is to cause waves there," said Paris. That is why FOX 10 Phoenix has decided to protect Dolores' identity.
"She's just afraid that it's going to put a target on her back," said Paris. "She doesn't know how the rest of the employees would handle this, nor her friends at the place. To up and move again would be tough on her."
In the course of this story, FOX 10 Phoenix's John Hook discovered caregivers in Arizona are not licensed, but are allowed to handle and dispense medication, including opioids.