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 107 employees. This review focused on seven operational activities. The facility complied with selected standards in the environment of care activity. The facility’s reported accomplishments were a lean project success in wheelchair management, the offering of Kids’ Korner services to veterans, and the receipt of the Energy Star® Award for the past 5 years. OIG made recommendations for improvement in the following six activities: (1) quality management, (2) medication management – controlled substances inspections, (3) coordination of care – hospice and palliative care, (4) pressure ulcer prevention and management, (5) nurse staffing, and (6) construction safety.