Pain prevalence in nursing homes remains high, with multiple resident, staff, and physician barriers presenting serious challenges to its improvement.The study aims were to (1) develop and test a multifaceted, culturally competent intervention to improve nursing home pain practices; (2) improve staff, resident, and physician knowledge and attitudes about pain and its management; (3) improve actual pain practices in nursing homes; and (4) improve nursing home policies and procedures related to pain.A multifaceted, culturally competent intervention was developed and tested in six Colorado nursing homes, with another six nursing homes serving as control sites. Both educational and behavioral change strategies were employed.The intervention was successful in improving the percentage of residents reporting constant pain in the treatment homes. Contextual factors (implementation of Medicare's Nursing Home Compare report card) appeared to exert a positive influence on pain documentation. There was no reduction in the percentage of residents reporting pain or reporting moderate/severe pain.Multiple challenges to quality improvement exist in nursing homes. Turnover of nursing staff reduced actual exposure to the intervention, and turnover of directors of nursing influenced constancy of message and overall facility stability. Residents often failed to report their pain, and physicians were reluctant to alter their prescribing practices.Any intervention to improve pain management in nursing homes must target explicitly the residents, nursing home staff, and primary care physicians. Implementation strategies need to accommodate the high turnover rates among staff, as well as the changes among the nursing home leadership.Pain is a complex problem in the nursing home setting. Multiple factors must be considered in both the design and implementation of interventions to improve pain practices and reduce pain prevalence in nursing homes.