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 142 employees. This review focused on seven operational activities. The facility complied with selected standards in the environment of care activity. The facility’s reported accomplishment was an all-terrain vehicle experience for veterans with disabilities. OIG made recommendations for improvement in the following six activities: (1) quality management, (2) medication management, (3) coordination of care, (4) nurse staffing, (5) pressure ulcer prevention and management, and (6) community living center resident independence and dignity.