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 446 employees. This review focused on seven operational activities. The facility complied with selected standards in the following two activities (1) long-term home oxygen therapy and (2) nurse staffing. The facility’s reported accomplishments were hospice and palliative care program comfort items and the Orthopedic Surgery Department System Redesign Project. OIG made recommendations for improvement in the following five activities: (1) quality management, (2) environment of care, (3) medication management – controlled substances inspections, (4) coordination of care – hospice and palliative care, and (5) preventable pulmonary embolism.