Background: Older adults with advanced cancer residing in nursing homes (NHs) are a vulnerable population that has not been well studied in terms of clinical needs and health care utilization. We sought to describe the clinical characteristics of these patients and examine their burdensome care transitions at the EOL. Methods: We conducted a retrospective analysis of deceased older adults (> 65 yrs) with advanced solid tumors (defined using Medicare claims, per prior literature) who resided in U.S. NHs and enrolled in Medicare fee-for-service (2008-2009). Medicare claims data were linked with geriatric assessments as part of the Minimum Data Set. Clinical characteristics, including comorbidities, pain scores, activities of daily living (ADLs) and cognition, were measured within 90 days of death. Using Medicare claims and per prior studies on end of life health care utilization, we defined a burdensome transition as two or more hospitalizations or an intensive care unit (ICU) admission in the last 90 days of life. Results: We included 34,670 patients with advanced solid tumors. Many residents had comorbid congestive heart failure (CHF) (29.3%), chronic obstructive pulmonary disease (COPD) (34.1%), and diabetes (35.0%). Over half (53.8%) had moderate or severe cognitive impairment; 66.5% were dependent in all ADLs, and 21.1% experienced daily pain. Only 55.4% of patients used hospice. 36.0% of patients experienced a burdensome transition at the EOL, and burdensome transitions were more common for patients who did not receive hospice (45.3% vs. 28.6%, p < 0.01). In adjusted analyses, the following characteristics were associated with a higher risk of a burdensome transition at the EOL: female sex (OR 1.2, P < 0.001), CHF (OR 1.56, P < 0.001), COPD (OR 1.3, P < 0.001), diabetes (OR 1.3, P < 0.001), full dependence in ADLs (OR 1.9, P < 0.001), and receipt of chemotherapy in the last 90 days of life (OR 1.7, P < 0.001). Conclusions: Although NH residents with advanced cancer have substantial comorbidities, cognitive deficits, and functional impairments, over a third experienced a burdensome care transition at the EOL. Interventions are critically needed to reduce burdensome transitions at EOL in this vulnerable population.