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 157 employees. This review focused on eight operational activities and one follow-up review area from the previous Combined Assessment Program review. The facility complied with selected standards in the following two activities (1) medication management – controlled substances inspections and (2) coordination of care – hospice and palliative care. The facility’s reported accomplishment was the Improving Our Work Is Our Work initiative to identify organizational improvement activities. OIG made recommendations for improvement in the following six activities and follow-up area: (1) quality management, (2) environment of care, (3) long-term home oxygen therapy, (4) nurse staffing, (5) preventable pulmonary embolism, (6) construction safety, and (7) follow-up on emergency/urgent care operations issues.