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 30 employees. This review focused on seven operational activities. The facility complied with selected standards in the following four activities: (1) environment of care, (2) medication management – controlled substances inspections, (3) long-term home oxygen therapy, and (4) nurse staffing. The facility’s reported accomplishments were organizational trust development and a veteran centered approach to decision making. OIG made recommendations for improvement in the following three activities: (1) quality management, (2) coordination of care – hospice and palliative care, and (3) preventable pulmonary embolism.