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 47 employees. This review focused on seven activities. The facility’s reported accomplishment was a pharmacy initiative to enhance medication safety and patient compliance, which also resulted in inventory reduction and cost savings. OIG made recommendations for improvement in all seven activities: (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) nurse staffing, and (7) construction safety.