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