Background: Interventions to improve the fracture prevention in nursing homes are needed. Methods: Cluster-randomized, single-blind, controlled trial of a multi-modal quality improvement intervention. Nursing homes (n = 67) with ≥10 residents with a diagnosis of osteoporosis or recent hip fracture (n = 606) were randomized to receive an early or delayed intervention consisting of audit and feedback, educational modules, teleconferences, and academic detailing. Medical record abstraction and the Minimum Data Set were used to measure the prescription of osteoporosis therapies before and after the intervention period. Analysis was at the facility-level and Generalized Estimating Equation modeling was used to account for clustering. Results: No significant improvements were observed in any of the quality indicators. The use of osteoporosis pharmacotherapy or hip protectors improved by 8.0% in the intervention group and 0.6% in the control group, but the difference was not statistically significant (P = .72). Participation in the intervention activities was low, but completion of the educational module (odds ratio [OR] 4.8, 95% confidence interval [CI], 1.9-12.0) and direct physician contact by an academic detailer (OR 4.5, 95% CI, 1.1-18.2) were significantly associated with prescription of osteoporosis pharmacotherapy or hip protectors in multivariable models. Conclusions: Audit-feedback and education interventions were ineffective in improving fracture prevention in the nursing home setting, although results may have been tempered by low participation in the intervention activities. © 2007 Elsevier Inc. All rights reserved.