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 35 employees. This review focused on seven operational activities. The facility complied with selected standards in the following three activities: (1) medication management – controlled substances inspections, (2) long-term home oxygen therapy, and (3) preventable pulmonary embolism. The facility’s reported accomplishments were collaborating with the Clarksburg Mission to establish transitional housing for returning female veterans and increasing the telehealth services offered at the facility. OIG made recommendations for improvement in the following four activities: (1) quality management, (2) environment of care, (3) coordination of care – hospice and palliative care, and (4) nurse staffing.