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 20 employees. This review focused on seven operational activities. The facility complied with selected standards in the following two activities (1) environment of care and (2) preventable pulmonary embolism. The facility’s reported accomplishments were the continued success of the research and development program in 2012 and the Certified Registered Nurse Anesthetist Succession Plan. OIG made recommendations for improvement in the following five activities: (1) quality management, (2) medication management – controlled substances inspections, (3) coordination of care – hospice and palliative care, (4) long-term home oxygen therapy, and (5) nurse staffing.