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 62 employees. This review focused on six operational activities. The facility complied with selected standards in the following four activities: (1) quality management, (2) environment of care, (3) medication management – controlled substances inspections, and (4) nurse staffing. The facility’s reported accomplishments were the implementation of a new Radiation Oncology Program and continued outreach in the Homeless Veterans Program. OIG made recommendations for improvement in the following two activities (1) coordination of care – hospice and palliative care and (2) pressure ulcer prevention and management.