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 544 employees. This review focused on seven operational activities and one follow-up review area from the previous Combined Assessment Program review. The facility complied with selected standards in the nurse staffing activity. The facility’s reported accomplishment was the remodeled Sterile Processing Service. OIG made recommendations for improvement in the following six activities and the follow-up area from the previous Combined Assessment Program review: (1) quality management, (2) environment of care, (3) medication management – controlled substances inspections, (4) coordination of care – hospice and palliative care, (5) long-term home oxygen therapy, (6) preventable pulmonary embolism, and (7) follow-up on environment of care rounds.