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 160 employees. This review focused on eight operational activities. The facility complied with selected standards in the following three activities: (1) medication management – controlled substances inspections, (2) nurse staffing, and (3) preventable pulmonary embolism. The facility’s reported accomplishments were an Interdisciplinary Medical Perioperative Assessment Consultation and Treatment Service and a full-home simulation training program in the community living center. 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) construction safety.