Nursing home regulatory agencies are subjected to a variety of pressures. Nursing home residents' families and friends want the agencies to "get tough" while the nursing home industry wants agencies to act as consultants rather than cops. The task of regulating nursing homes in the United States is primarily carried out by units of state government, operating under Medicaid certification guidelines and procedures set by the Health Care Financing Administration. State agencies in fact have enormous discretion as to how the guidelines will be interpreted, what level of compliance will be expected, and when and how non-compliance will be penalized. Data on the imposition of penalties by the states show enormous variations in which penalties (fines, decertification, etc.) are used, and what proportion of facilities are penalized. The states with more facilities are more likely to use penalties; few other correlations appear. (An appendix details the lack of reliable data on regulatory enforcement and the reasons why available data do not permit comparisons of states' enforcement policies.) (Author/ABL)