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 220 employees. This review focused on seven operational activities. The facility complied with selected standards in the following three activities: (1) quality management, (2) pressure ulcer prevention and management, and (3) nurse staffing. The facility’s reported accomplishments were launching the veterans mobile medical unit, achieving perfect accreditation with exemplary conformance from the Commission on Accreditation of Rehabilitation Facilities International, implementing the cochlear implant program, and implementing the da Vinci® Surgical System. OIG made recommendations for improvement in the following four activities: (1) environment of care, (2), medication management – controlled substances inspections, (3) coordination of care – hospice and palliative care, and (4) construction safety.