Regulatory oversight aims to promote quality of care in US nursing homes. A survey of long-term care (LTC) inspection practices in a Veterans Administration network in 2006 revealed great variability in monitoring and reporting processes, with opportunities for improvement. Modern organization theory and the PARIHS Implementation Framework provide a model for process improvement to enhance oversight for LTC facilities. Over a 3-year time frame, 6 facility inspection teams utilized a modified Delphi approach to arrive at and adopt a standardized structured inspection process. In the 2 districts where 10 facility contracts were terminated for quality deficits identified as a result of process improvement, Star Ratings of approved facilities improved (3.2 to 3.3). The 10 facilities terminated had a mean rating of 1.2 (0.48) (t = 3.87, P < .01). Standardization of a structured LTC inspection process enhances organizational oversight and may contribute to improved quality of care.