Noah Berger for The Bay Citizen

Martin Titcomb with his wife, Lydia, in a residential care home in San Bruno. He has Parkinson’s, and he now takes Seroquel safely.

“When pharmacy services are provided below cost, the pharmacist may be recouping the losses by making drug recommendations according to financial incentives instead of the best interests of the residents,” said Anthony Chicotel, a lawyer with the California Advocates for Nursing Home Reform, which plans to release a report on the state investigations. “When their independence is compromised, the integrity of their protective function is eviscerated.”

The state investigations yielded a number of examples where the pharmacists’ protective function appeared to be compromised.

At Hillside Senior Care nursing home in Fremont, for example, a consulting pharmacist was billed at a rate as low as $16.24 an hour, and no more than $19.16 an hour, between January and May 2011. In the same period, according to state investigators, a pharmacist at Hillside contradicted a doctor’s request to cut back antipsychotic medication.

“We have corrected this already with the department,” said Vilmar Agustin, Hillside’s director of nursing.

At the Herman Health Care Center in San Jose, investigators found that between August 2010 and January 2011, pharmacist services were billed for as little as $23.75 an hour and not more than $29.75. The state also found prescription irregularities.

Mandy Sollis, Herman Health’s business office director, wrote in an email: “We did increase our rate of pay to the pharmacy per regulations.” She would not specify the amount, saying it was private.

In the case of the elderly woman in Campbell who was prescribed drugs that the state investigators said were potentially life-threatening, “With regard to the investigation, I know there was a deficiency and a plan of correction,” said Ed Basa, who had been the administrator at Greenhills Manor at the time of the investigation last June.

At the Empress Care Center in San Jose, investigators found that a resident was kept on Risperdal and that the dosage was increased “without evidence of effectiveness over an eight-month period.” Another patient was on the antipsychotics Seroquel and Haldol, despite side effects that included “continuous lip smacking and shaking of the arms and legs.”

The resident told investigators “he had been like that for a very long time.” But the state found nothing in the resident’s chart to indicate that he suffered from side effects.

In another case at Empress, the state found that a resident with dementia who “refused to shower, dress and be groomed” was prescribed Zyprexa, one of a group of medications called “atypical” antipsychotics, which the Food and Drug Administration warned in 2005 were not approved for use in elderly people with dementia because they increase their risk of dying. That warning was extended in 2008 to include older antipsychotic drugs like Haldol.

Administrators at the Empress Care Center did not return calls asking for comment.

Anita Gore, a spokeswoman for the California Department of Public Health, said the recent investigations prompted her agency to pass a regulation limiting the prescription of antipsychotics for Medi-Cal recipients in nursing homes to uses approved by the federal Food and Drug Administration.

As a matter of routine, Gore said, nursing homes found by the state to be deficient have 10 days to submit plans of correction, but they can request an extension. “There is no set deadline for submitting a plan of correction,” she said.

Chicotel of California Advocates for Nursing Home Reform said he was disappointed with the state’s response to its own findings. Chicotel said he was concerned that “not a single facility was issued a citation or fined.”

This article also appears in the Bay Area edition of The New York Times.