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 74 employees. This review focused on seven operational activities. The facility complied with selected standards in the following three activities: (1) medication management, (2) coordination of care, and (3) community living center resident independence and dignity. The facility’s reported accomplishments were a revamped Systems Redesign program, the Green Award, and the Computed Tomography Optimization Project. OIG made recommendations for improvement in the following four activities: (1) quality management, (2) environment of care, (3) nurse staffing, and (4) pressure ulcer prevention and management.