The purpose of the review was to evaluate selected operations, focusing on patient care quality and the environment of care. During the review, OIG provided crime awareness briefings to 329 employees. This review focused on eight operational activities. The facility complied with selected standards in the following four activities: (1) environment of care, (2) medication management – controlled substances inspections, (3) long-term home oxygen therapy, and (4) nurse staffing. The facility’s reported accomplishments were the successful pilot of a stand-alone outpatient dialysis unit, the availability of teleaudiology and teledermatology services for veterans outside of the facility’s commuting area, and the use of the patient safety Simulation Center to identify performance opportunities. OIG made recommendations for improvement in the following four activities: (1) quality management, (2) coordination of care – hospice and palliative care, (3) preventable pulmonary embolism, and (4) construction safety.