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 253 employees. This review focused on six operational activities. The facility complied with selected standards in the following two activities (1) medication management and (2) coordination of care. 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.