In March 2011, after federal inspectors visited Keeneland Nursing and Rehab, a Weathorford nursing home, the Centers for Medicare & Medicaid Services issued a report detailing a laundry list of concerns.

The report concluded that staff were medicating patients unnecessarily so they'd be easier to deal with. One nurse reportedly punished an uncooperative patient (she had demanded buttermilk at a meal) by giving her a shot of sterile water while two co-workers held her down. That incident wasn't reported, as suspected abuse is required to be, nor was an incident in which a patient was found face-down in a pool of blood, having spilled from the wheelchair.

All told, CMS cited Keeneland for 22 violations of nursing home standards, fined the facility $80,000, and suspended one of its regular Medicare payments. It had been fined $65,000 eight months before for failing to provide high-quality care. And the facility is not alone.

More nursing homes in Texas have been cited for serious violations than in any other state, according to data compiled by ProPublica, which is conducting an ongoing investigation into the country's nursing homes. (Texas' No. 1 status is partly due to size, having more nursing homes than any other state except for California. It ranks 11th in the number of serious deficiencies per nursing home.)

ProPublica doesn't speculate why Texas or other states have so many problem nursing homes, but a piece posted to the site yesterday suggests that it likely has something to do with the Balkanized system of enforcement.

For the most part, the fines levied on nursing homes are determined by states, with token approval from CMS. Some states have a tendency to bring down the hammer. Others, like Texas, prefer slaps on the wrist.

Monday's ProPublica story gives an example: Two nursing home patients, one in Hughes Springs, Texas, the other in North Augusta, South Carolina, die preventable deaths. Inspectors in both places come to the identical conclusion that the facilities had failed to operate "in an acceptable way that maintains the well-being of each resident."

The Texas home got off with a $9,500 fine, while the one in South Carolina had to pay $305,370. The average fine paid by a South Carolina nursing home in the past three years was $40,507. The average fine in Texas: $6,933.

Cecilia Cavuto, a spokeswoman for Texas' Department of Aging and Disability Services, told ProPublica that Texas chooses its actions based on "the nature of the deficiencies identified, prior success or failure of previous remedies, and staff's professional judgment regarding what remedy might best encourage a facility to come back into compliance with Medicare/Medicaid requirements."

South Carolina does the same thing and manages to appear much more concerned about cracking down on poorly managed elder-care facilities.