The Centers for Medicare and Medicaid Serv. (CMS) established the Special Focus Facility (SFF) Program to help address poor nursing home performance. States select a subset of homes as SFFs from a list of the 15 poorest performing homes in each state. States survey SFFs twice as frequently as other homes and there are more robust enforcement, including termination, for SFFs that fail to improve within about 18 months. This report: (1) determined the factors states consider in selecting SFFs and how SFFs differed from other nursing homes; (2) evaluated CMS regional office and state adherence to program guidance and the program's impact on homes' performance; and (3) identified other strategies that were used to improve poorly performing homes.