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 61 employees. This review focused on eight activities. The facility complied with selected standards in the following three activities: (1) medication management – controlled substances inspections, (2) coordination of care – hospice and palliative care, and (3) preventable pulmonary embolism. The facility’s reported accomplishments were VA Kids Care, the Mobile Unit Podiatry Program, and a Spirit of Planetree Award. 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) construction safety.