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 221 employees. This review focused on seven operational activities. The facility complied with selected standards in coordination of care – hospice and palliative care. The facility’s reported accomplishments were a partnership with the Chicago Housing Aurthority and the Department of Housing and Urban Development to reduce homelessness for Chicago area veterans and their families and the Project Red Initiative, a program designed to reduce readmission rates of congrestive heart failure patients. OIG made recommendations for improvement in the following six activities: (1) quality management, (2) environment of care, (3) medication management – controlled substances inspections, (4) pressure ulcer prevention and management, (5) nurse staffing, and (6) construction safety.