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 91 employees. This review focused on eight operational activities. The facility complied with selected standards 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. The facility’s reported accomplishments were the Coordinated-Transitional Care Program and the Septic Shock Protocol. OIG made recommendations for improvement in the following three activities: (1) medication management – controlled substances inspections, (2) preventable pulmonary embolism, and (3) construction safety.