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 294 employees. This review focused on seven operational activities. The facility’s reported accomplishments were its Homeless Program and recognition as a Joint Commission top performer. OIG made recommendations for improvement in all seven of the following activities: (1) quality management, (2) environment of care, (3) medication management, (4) coordination of care, (5) nurse staffing, (6) pressure ulcer prevention and management, and (7) community living center resident independence and dignity.