This study presents interview and statistical data from a telephone and fax survey of state agency officials and statistical data from the Centers for Medicare & Medicaid Services' Online Survey Certification and Reporting(OSCAR) system. State survey activities for nursing facilities were reviewed and the number and types of intermediate sanctions issued by states in l999 were reported, along with barriers to the use of such sanctions. Using five selected enforcement measures to create a summary score, states were classified by quartiles based on the stringency of their nursing facility enforcement activities. Controlling for the number of complaints as a proxy for quality, the predictors of a summary of state enforcement actions were:percentage of population at age eighty-five and above, Democratic governors,higher percentages of chain facilities, and lower facility occupancy rates. Regional differences in enforcement patterns also were shown. Many federal policies and resource constraints were identified as barriers to effective regulation. The findings identified nursing facility survey and enforcement issues that need to be addressed by policy makers.