||This sequential mixed methods study examined factors associated with quality care and financial viability of rural nursing homes in the Mountain West. Rural nursing homes were sampled from the Online Survey Certification and Reporting system and Skilled Nursing Facility cost report databases, resulting in 161 cases. Financial data were not available on all nursing homes, which decreased the sample to 74. Qualitative interviews were conducted with a subsample of Administrators and Directors of Nursing (n = 30) from 23 nursing homes. Rural Mountain West nursing homes were smaller, and had lower occupancy rages, and more government/country affiliated homes compared to nursing homes nationwide. There were differences in facility size, Medicare occupancy, and the presence of Alzheimer's beds on location suggesting that isolated areas lack the demand for services or the resources necessary to provide specialized care. Forty-one percent of nursing homes changed ownership. Nursing homes did not vary in health deficiencies or staffing hours or mix. The median profit margin for rural nursing homes (N = 74) was 4.73; but 35% had a negative margin. Higher Medicaid utilization was associated with higher weighted deficiency scores implying lower quality. Those providing better quality, indicated by staffing levels were smaller or government/county affiliated. Medicare occupancy and nursing home size were key predictors of financial viability (R2 = .26,F (4, 73)=6.04,p < .001). On average, Administrators and Directors of Nursing had been in their leadership positions slightly over 5 years. Competition for staff was reported as a common problem. Contract service challenges were related to transporting residents, sometimes hundreds of miles for services. Nursing homes that had more progressive continuing education programs showed higher quality care. However, modern approaches to monitor and improve quality, such as total quality management did not exist. Quality in rural nursing homes is precarious evidenced by low profit margins, ownership changes, and few specialized services. Data from this study illustrated that characteristics of quality and profitability were mixed, at times contrasting, and sometimes differing from expected. Results suggest that when needing to obtain quality nursing home care some older adults in rural communities remain underserved.