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 136 employees. This review focused on seven operational activities. The facility complied with selected standards in the following three activities: (1) coordination of care – hospice and palliative care, (2) pressure ulcer prevention and management, and (3) nurse staffing. The facility’s reported accomplishments were implementation of an innovative medication safety curriculum and the Comprehensive Pain Center, which offers interdisciplinary pain rehabilitation programs. OIG made recommendations for improvement in the following four activities: (1) quality management, (2) environment of care, (3) medication management – controlled substance inspections, and (4) construction safety.