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 218 employees. This review focused on seven operational activities. The facility complied with selected standards in the following two activities (1) medication management – controlled substances inspections and (2) coordination of care – hospice and palliative care. The facility’s reported accomplishment was its Long-Term Home Oxygen Therapy Program team. OIG made recommendations for improvement in the following five activities: (1) quality management, (2) environment of care, (3) long-term home oxygen therapy, (4) nurse staffing, and (5) preventable pulmonary embolism.