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 233 employees. This review focused on eight operational activities. The facility complied with selected standards in the following five activities: (1) medication management – controlled substances inspections, (2) coordination of care – hospice and palliative care, (3) nurse staffing, (4) preventable pulmonary embolism, and (5) construction safety. The facility’s reported accomplishments were the Operation War Fighter program, the Healthcare for Homeless Program, and art programs. OIG made recommendations for improvement in the following three activities: (1) quality management, (2) environment of care, and (3) long-term home oxygen therapy.