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 116 employees. This review focused on six operational activities. The facility complied with selected standards in nurse staffing. The facility’s reported accomplishment was hosting the 32nd National Veterans Wheelchair Games in June 2012. OIG made recommendations for improvement 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) pressure ulcer prevention and management.