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 273 employees. This review focused on seven operational activities and one follow-up review area from the previous Combined Assessment Program review. The facility complied with selected standards in the following two activities (1) medication management and (2) coordination of care. OIG made recommendations for improvement in the following six activities, including the follow-up review area: (1) quality management, (2) environment of care, (3) nurse staffing, (4) pressure ulcer prevention and management, (5) community living center resident independence and dignity, and (6) follow-up on environment of care rounds attendance.