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 379 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. The facility’s reported accomplishments were the use of the Vision-Analysis-Team-Aim-Map-Measure-Change-Sustain framework to reduce incontinence associated dermatitis and a successful multidisciplinary workgroup for specialty care access. 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.