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 seven operational activities and one follow-up review area from the previous Combined Assessment Program review. The facility complied with selected standards in the following two activities (1) quality management and (2) coordination of care – hospice and palliative care. The facility’s reported accomplishments were the implementation of the Geriatric Resources for Assessment and Care of Elders Program and the Mobile Prosthetic Van Program. OIG made recommendations for improvement in the following five activities and follow-up review area: (1) environment of care, (2) medication management – controlled substances inspections, (3) pressure ulcer prevention and management, (4) nurse staffing, (5) construction safety, and (6) follow-up on environment of care issue.