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 215 employees. This review focused on eight operational activities. The facility complied with selected standards in the following three activities: (1) environment of care, (2) nurse staffing, and (3) preventable pulmonary embolism. The facility’s reported accomplishments were the reduction in solid and regulated waste volumes, the community living center’s culture transformation, and the implementation of new system redesign strategies to support process improvement activities. OIG made recommendations for improvement in the following five activities: (1) quality management, (2) medication management – controlled substance inspections, (3) coordination of care – hospice and palliative care (4) long-term home oxygen therapy, and (5) construction safety.