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 67 employees. This review focused on seven operational activities. The facility complied with selected standards in the following four activities: (1) coordination of care – hospice and palliative care, (2) pressure ulcer prevention and management, (3) nurse staffing, and (4) construction safety. The facility’s reported accomplishments were performance improvement projects, the Patient Safety Program, and the decrease in the incidence of hospital-acquired pressure ulcers. OIG made recommendations for improvement in the following three activities: (1) quality management, (2) environment of care, and (3) medication management – controlled substances inspections.