At the request of Senator John Heinz, the General Accounting Office (GAO) conducted a study on the quality of care provided to nursing home residents to determine the extent of repeated noncompliance with federal requirements that could affect resident health and safety and to evaluate the adequacy of federal and state enforcement actions to correct the deficiencies. The study was conducted in Arkansas, California, Connecticut, Kansas, and Wisconsin. The GAO identified nursing home requirements that most directly affected resident care, health, or safety; analyzed nursing homes' compliance with those requirements during the four most recent inspections; developed detailed case studies on 26 judgmentally selected nursing homes to evaluate the adequacy of enforcement actions; reviewed federal and state laws relating to nursing home care; evaluated potential alternative sanctions; and interviewed federal, state, and private sector officials. The results revealed that repeated noncompliance was widespread, that nursing homes with serious deficiencies avoided penalties, and that alternative penalties were needed. Based on these findings, the GAO recommended passage of federal legislation to establish a wide range of alternative sanctions for noncompliance with nursing home requirements. (NB)