Nursing homes are arguably the most criticized sector of the US health care system. In fact, the nursing home industry's entire history has been marked by cycles of public clamor for improvement and ineffective governmental responses. Over the past century, multiple attempts to improve the quality of nursing home care have had limited success. This article reviews these initiatives from the era of the poorhouse to the most recent reform law, implemented during the last decade. An analysis suggests that the historical reliance on government regulation has not ensured nursing home quality. Future efforts should address the most glaring weaknesses of nursing home regulation, including the lack of standardization of the survey and enforcement processes. In addition, new strategies are needed beyond a reformed inspection system. This article demonstrates that while the exact path to nursing home quality is somewhat uncertain, retracing history's steps will not lead nursing homes in the desired direction.