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 170 employees. This review focused on seven operational activities. The facility complied with selected standards in the following three activities: (1) environment of care, (2) coordination of care – hospice and palliative care, and (3) nurse staffing. The facility’s reported accomplishment was a health video mailing system of 16 different commercially produced videos that have reinforced interventions for improved care for rural veterans. OIG made recommendations for improvement in the following four activities: (1) quality management, (2) medication management – controlled substance inspections, (3) pressure ulcer prevention and management, and (4) construction safety.