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 264 employees. This review focused on seven operational activities. The facility complied with selected standards in the following three activities: (1) nurse staffing, (2) pressure ulcer prevention and management, and (3) community living center resident independence and dignity. The facility’s reported accomplishments were receipt of funding from the Veterans Health Administration Innovation Initiative for implementation of a multisensory environment for dementia care and the caregivers support program. OIG made recommendations for improvement in the following four activities: (1) quality management, (2) environment of care, (3) medication management, and (4) coordination of care.