The purpose of the review was to evaluate selected health care facility operations, focusing on patient care quality and the environment of care. This review focused on 12 operational activities. The facility complied with selected standards in the following four activities (1) continuity of care, (2) emergency management, (3) women’s health, and (4) credentialing and privileging. The facility’s reported accomplishments were improved pharmacy processing, improved beneficiary travel claim processing, and improved access and coordination. OIG made recommendations for improvement in the following eight activities: (1) quality management, (2) environment of care, (3) medication management – controlled substances inspections, (4) suicide prevention, (5) vaccinations, (6) diabetic foot care, (7) management of test results, and (8) management of workplace violence.