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 42 employees. This review focused on six operational activities. The facility complied with selected standards in the following three activities: (1) environment of care, (2) medication management – controlled substances inspections, and (3) coordination of care – hospice and palliative care. The facility’s reported accomplishments were the Cheyenne VAMC (VA medical center) and Clinics Planning Model and improvements in the Controlled Substances Inspection Program. OIG made recommendations for improvement in the following three activities: (1) quality management, (2) pressure ulcer prevention and management, and (3) nurse staffing.