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 207 employees. This review focused on seven operational activities. The facility complied with selected standards in the following two activities (1) coordination of care and (2) nurse staffing. The facility’s reported accomplishment was the establishment of the Veterans Justice Outreach Program. OIG made recommendations for improvement in the following five activities: (1) quality management, (2) environment of care, (3) medication management, (4) pressure ulcer prevention and management, and (5) community living center resident independence and dignity.