This Study uses Organizational Theory, Social Movement Theory, and Critical Theory to analyze a local long term care ombudsman program (LTCOP) effectiveness in and ability to conduct systems advocacy. A case study methodology was used to conduct telephone survey interviews with local LTCOP coordinators in Georgia to examine more closely systems advocacy within their local LTCOPs and factors that influence effectiveness in conducting systems advocacy. Influencing factors measured include resources, program autonomy, and inter-organizational relationships. Georgia interview and National Ombudsman Reporting System (NORS) data were collected from 2006–2007. Data from similar projects in New York and California are then used evaluate both within and across-state differences in factors influencing local LTCOP effectiveness in and ability to conduct systems advocacy. Findings show that while all factors were found to impact local LTCOP effectiveness in and ability to conduct systems advocacy in each state, the results were variable within as well as across states. Organizational Theory, Social Movement Theory, and Critical Theory inform a discussion about potential explanations for the differential impact of resources, autonomy, and inter-organizational relationships on local LTCOP within and across states. Knowledge and understanding concerning barriers to effective program operation and successful programmatic approaches are essential to enhance the safety and well-being of those residing in LTC facilities, to strengthen local LTCOPs, and to develop meaningful public policy.