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 32 employees. This review focused on seven operational activities. The facility complied with selected standards in the following four activities: (1) medication management – controlled substances inspections, (2) long-term home oxygen therapy, (3) nurse staffing, and (4) preventable pulmonary embolism. The facility’s reported accomplishments were improving veteran-centered care in the mental health clinic and high scores within the Hospice and Palliative Care Program. OIG made recommendations for improvement in the following three activities: (1) quality management, (2) environment of care, and (3) coordination of care – hospice and palliative care.