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 543 employees. This review focused on six operational activities. The facility’s reported accomplishments were transitional housing for homeless veterans, a nurse residency program, and health care equity leader status. OIG made recommendations for improvement in all six of the following activities: (1) quality management, (2) environment of care, (3) medication management, (4) coordination of care, (5) nurse staffing, and (6) pressure ulcer prevention and management.