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 230 employees. This review focused on seven operational activities. The facility complied with selected standards in the following two activities (1) environment of care and (2) long-term home oxygen therapy. The facility’s reported accomplishments were the new facility and clinic activation, the secure messaging program, and patient-centered care initiatives at the new facility. OIG made recommendations for improvement in the following five activities: (1) quality management, (2) medication management – controlled substances inspections, (3) coordination of care – hospice and palliative care, (4) nurse staffing, and (5) preventable pulmonary embolism.