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 496 employees. This review focused on six operational activities. The facility complied with selected standards in the following two activities (1) quality management and (2) environment of care. The facility’s reported accomplishment was the congestive heart failure systems redesign. OIG made recommendations for improvement in the following four activities: (1) medication management – controlled substances inspections, (2) coordination of care – hospice and palliative care, (3) pressure ulcer prevention and management, and (4) nurse staffing.