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 110 employees. This review focused on eight operational activities. The facility complied with selected standards in the long-term home oxygen therapy activity. The facility’s reported accomplishments included developing and activating the first-of-its-kind integrated VA and Department of Defense Federal Health Care Center and having two of its Lean Six Sigma performance improvement projects featured on Joint Commission Resources Quality and Safety Network. OIG made recommendations for improvement in the following seven activities: (1) quality management, (2) environment of care, (3) medication management – controlled substances inspections, (4) coordination of care – hospice and palliative care, (5) nurse staffing, (6) preventable pulmonary embolism, and (7) construction safety.