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 148 employees. This review focused on eight operational activities and a follow-up review area from the previous Combined Assessment Program review. The facility complied with selected standards in the following three activities: (1) environment of care, (2) medication management – controlled substances inspections, and (3) preventable pulmonary embolism. The facility’s reported accomplishment was innovation in environment of care rounds. OIG made recommendations for improvement in the following six activities, including the follow-up review area: (1) quality management, (2) coordination of care – hospice and palliative care, (3) long-term home oxygen therapy, (4) nurse staffing, (5) construction safety, and (6) follow-up on coordination of care issue.