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 175 employees. This review focused on six operational activities. The facility’s reported accomplishment was the achievement of an employee flu vaccination rate of 76 percent compared to the national average of 48 percent. OIG made recommendations for improvement in all six of the following activities: (1) quality management, (2) environment of care, (3) medication management – controlled substances inspections, (4) coordination of care – hospice and palliative care, (5) pressure ulcer prevention and management, and (6) nurse staffing.