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 492 employees. This review focused on seven operational activities. The facility complied with selected standards in the medication management activity. The facility’s reported accomplishments were an innovative geriatric medical health model, Joint Commission recognition, Affordable Care Act initiatives, and a patient-centered after visit summary. OIG made recommendations for improvement in the following six activities: (1) quality management, (2) environment of care, (3) coordination of care, (4) nurse staffing, (5) pressure ulcer prevention and management, and (6) community living center resident independence and dignity.