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 218 employees. This review focused on seven operational activities. The facility complied with selected standards in the following three activities: (1) environment of care, (2) medication management, and (3) coordination of care. The facility’s reported accomplishments were the opening of a physical therapy satellite clinic in the community living center and the Veterans Transportation Service, which provides timely and efficient transportation to outpatients traveling to and from scheduled medical appointments at the facility. OIG made recommendations for improvement in the following four activities: (1) quality management, (2) nurse staffing, (3) pressure ulcer prevention and management, and (4) community living center resident independence and dignity.