This study investigated the physical environment and organizational factors that influenced the process of providing care to terminally ill nursing home residents.Design and Methods:Participant observation, interviews, and event analysis were used to obtain data in two proprietary facilities.Results:The physical environment was not conducive to end-of-life care. The rooms were crowded, there was little privacy, and the facilities were noisy. Inadequate staffing and lack of supervision were among the most significant organizational factors that influenced care. Often, residents did not receive basic care, such as bathing, oral hygiene, adequate food and fluids, and repositioning. A consequence of inadequate staffing was the development of pressure ulcers; 54% of the residents had pressure ulcers; 82% of these residents died with pressure ulcers.Implications:Findings suggest that the nursing home environment in these two facilities, as now structured, is an inappropriate setting for end-of-life care.