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 442 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 following three activities: (1) environment of care, (2) medication management – controlled substances inspections, and (3) nurse staffing. The facility’s reported accomplishments were hospice and palliative care education and imaging advances. OIG made recommendations for improvement in the following five activities and the follow-up review area: (1) quality management, (2) coordination of care – hospice and palliative care, (3) long-term home oxygen therapy, (4) preventable pulmonary embolism, and (5) follow-up on environment of care issue.