Pain assessment in nursing home residents poses challenges since many of these individuals are too cognitively impaired to respond to traditional self-report instruments. Assessment of pain behavior in this population offers a logical alternative. The purpose of this study was to compare perceptions of behaviors identified as being pain-related in 42 nursing home residents with chronic pain, as reported by residents themselves, their nursing home caregivers and their family caregivers. Our specific research agenda was to identify the most salient behaviors that signal pain in nursing home residents; to determine the test-retest agreement of residents' self-perceived pain behaviors; to learn of the confidence that caregivers feel regarding assessment of residents' pain behavior; and to examine the agreement between caregivers and residents about pain behaviors in particular residents. We also wanted to compare residents' and caregivers' ratings of the residents' pain intensity. Finally, we explored the beliefs of nursing home staff about the influence of dementia on pain and pain assessment. Twenty-two of 26 pain-related behaviors identified by residents showed fair to perfect test-retest agreement (kappas 0.40-1). For the vast majority of pain-related behavior items, kappas for resident-caregiver agreement were <0.30. Agreement with regard to pain intensity was similarly poor (r = -0.19-0.34). Confidence in pain rating was high for both nurse (on average, 7.2 on a scale of 0-10) and family (on average, 6.7) caregivers. Seventy-one percent of nurses felt that pain assessment is more difficult in demented individuals, but that cognitive function does not influence pain prevalence. While nursing home residents with chronic pain and their caregivers have different perceptions regarding which behaviors are pain-related, additional studies are required to determine the underpinnings of these differing perceptions and to determine the extent to which formal pain behavior observation protocols will be useful for evaluating nursing home residents with chronic pain.