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 106 employees. This review focused on six operational activities. The facility complied with selected standards in the following two activities (1) medication management – controlled substances inspections and (2) nurse staffing. The facility’s reported accomplishments were the geriatric suicide screening tool and the Green House® Project. OIG made recommendations for improvement in the following four activities: (1) quality management, (2) environment of care, (3) coordination of care – hospice and palliative care, and (4) construction safety.