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 323 employees. This review focused on eight operational activities. The facility complied with selected standards in the construction safety activity. The facility’s reported accomplishments were the hospice and palliative care memorial tribute book, simulation and experiential education, and the Quiet Campaign. 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) long-term home oxygen therapy, (6) nurse staffing, and (7) preventable pulmonary embolism.