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 118 employees. This review focused on eight operational activities. The facility’s reported accomplishment was implementing three initiatives to address issues with the homeless veteran population. OIG made recommendations for improvement in all eight of the following 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, (7) preventable pulmonary embolism, and (8) construction safety.