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 579 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 Mental Health Residential Rehabilitation Treatment Program activity. The facility’s reported accomplishments were the primary care – mental health integration program, a solar energy program, and a virtual pain management program. OIG made recommendations for improvement in the following activities and follow-up review area: (1) quality management, (2) environment of care, (3) medication management – controlled substances inspections, (4) coordination of care – hospice and palliative care, (5) pressure ulcer prevention and management, (6) nurse staffing, and (7) follow-up on environment of care issues.