ObjectiveTo determine the surgical procedures being done on long‐term care (level 2) nursing home residents and the resultant in‐hospital morbidity and mortality.DesignA retrospective chart review of inpatient medical records from two hospitals, identified by computerized search of medical records and/or referral by directors of nursing of area nursing homes.SettingPatients originated in skilled‐care nursing homes in New Castle County, Delaware, USA. Surgery was performed in the area's two major hospitals, one a 1000‐bed regional referral and teaching hospital, and the other a 300‐bed community hospital.PatientsResidents of skilled‐care nursing homes (level 2) who underwent major surgery between January 1979 and December 1989.Measurements and Main ResultsEighty procedures were performed in 74 patients. Many different types of procedures were done. After primary repair of hip fracture the most common procedures were non‐orthopedic extremity and abdominal surgeries. Three deaths occurred (mortality 3.8%), and all were in patients undergoing emergency surgery who were classified above American Society of Anesthesiology Class 3. Serious complications occurred in 43% of the procedures and were most commonly cardiopulmonary and psychiatric, including profound depression in four. Antibiotic‐associated colitis occurred in three patients and required a second surgical procedure in one. Fewer adverse outcomes were seen in patients undergoing elective surgical procedures with spinal or local anesthesia than in patients receiving general anesthesia.ConclusionsAlthough retrospective and limited to inpatient data, in‐hospital surgical mortality in this very frail population was low, comparable to series in unselected geriatric populations. However, major complications were very common. Primary hip surgery repair may have been too frequently done. A multi‐institution, prospective trial would be useful to assess functional outcome of surgery