The purpose of the review was to evaluate selected health care operations, focusing on patient care quality and the environment of care. During the review, OIG provided crime awareness briefings to 286 employees. This review focused on seven operational activities. The facility complied with selected standards in the following five activities: (1) medication management, (2) coordination of care, (3) nurse staffing, (4) pressure ulcer prevention and management, and (5) community living center resident independence and dignity. The facility’s reported accomplishment was increasing the availability and timeliness of scanned documents in the electronic health record. OIG made recommendations for improvement in the following two activities (1) quality management and (2) environment of care.