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 159 employees. This review focused on seven operational activities. The facility complied with selected standards in the following three activities: (1) coordination of care, (2) medication management, and (3) nurse staffing. The facility’s reported accomplishments were the Veterans Justice Outreach Program and the expansion of gastroenterology services. OIG made recommendations for improvement in the following four activities: (1) quality management, (2) environment of care, (3) pressure ulcer prevention and management, and (4) community living center resident independence and dignity.