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