Purpose of the study: Studies have shown that patient safety culture (PSC) is poorly developed in nursing homes (NHs), and, therefore, residents of NHs may be at risk of harm. Using Donabedian's Structure-Process-Outcome (SPO) model, we examined the relationships among top management's ratings of NH PSC, a process of care, and safety outcomes. Design and Methods: Using top management's responses from a nationally representative sample of 3,557 NHs on the 2008 Nursing Home Survey on PSC, the Online Survey, Certification, and Reporting Database, and the Minimum Data Set, we examined the relationships among the three components of Donabedian's SPO model: structure (PSC), a process of care (physical restraints), and patient safety outcomes (residents who fell). Results: Results from generalized estimating equations indicated that higher ratings of PSC were significantly related to lower prevalence of physical restraints (odds ratio OR = 0.997, 95% confidence interval CI = 0.995-0.999) and residents who fell (OR = 0.999, 95% CI = 0.998-0.999). Physical restraint use was related to falls after controlling for structural characteristics and PSC (OR = 1.698, 95% CI = 1.619-1.781). Implications: These findings can contribute to the development of PSC in NHs and promote improvements in health care that can be measured by process of care and resident outcomes.