This study examines the large-scale atmosphere-ocean environments that led to the winter tornado outbreak across the Ohio Valley on 10–11 December 2021, also known as the Quad-States Tornado Outbreaks. Here, we show that the Quad-States Tornado Outbreaks occurred under an exceptionally strong and prolonged negative Pacific-North American pattern (PNA), which developed around December 1 and persisted for a month. This unusual PNA produced a strong atmospheric ridge along the south and eastern US seaboard, which in turn helped warm the Gulf of Mexico and produced large-scale environments conducive for tornadogenesis across the Ohio Valley. Further analysis shows that a broad region across the Ohio Valley is particularly vulnerable to extensive winter tornado outbreaks during long-lived negative PNA, whereas a limited region in the central US is exposed to winter tornado activity during short-lived negative PNA. Finally, although the PNA is a mode of internal variability that occurs with or without El Niño—Southern Oscillation, the occurrence of prolonged negative PNA is more frequent during La Niña than during El Niño.