The purpose of the review was to evaluate selected health care facility operations, focusing on patient care quality and the environment of care. During the review, OIG provided crime awareness briefings to 635 employees. This review focused on six operational activities. The facility complied with selected standards in the following two activities (1) coordination of care – hospice and palliative care and (2) nurse staffing. The facility’s reported accomplishments were a community living center restorative gymnasium and orthopedic joint replacement services. OIG made recommendations for improvement in the following four activities: (1) quality management, (2) environment of care, (3) medication management – controlled substances inspections, and (4) pressure ulcer prevention and management.