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 155 employees. This review focused on six operational activities. The facility complied with selected standards in the following five activities: (1) quality management, (2) environment of care, (3) medication management – controlled substance inspections, (4) coordination of care – hospice and palliative care, and (5) nurse staffing. The facility’s reported accomplishments were pharmacy staff recognitions and collaboration efforts, pharmacy system cost savings and improvements, and the enteral feeding process redesign. OIG made recommendations for improvement in the pressure ulcer prevention and management activity.