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 170 employees. This review focused on seven operational activities. The facility’s reported accomplishment was the Final Salute for deceased veterans. OIG made recommendations for improvement in all seven of the following activities: (1) quality management, (2) environment of care, (3) medication management – controlled substances inspections, (4) coordination of care – hospice and palliative care, (5) pressure ulcer prevention and management, (6) nurse staffing, and (7) construction safety.