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 95 employees. This review focused on seven operational activities. The facility complied with selected standards in the following two activities (1) coordination of care and (2) medication management. The facility’s reported accomplishments were implementing a Centralized Business Office Center that provides a “one stop” shopping concept and serving as the host site for a VA-community mental health summit. OIG made recommendations for improvement in the following five activities: (1) quality management, (2) environment of care, (3) nurse staffing, (4) pressure ulcer prevention and management, and (5) community living center resident independence and dignity.