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 138 employees. This review focused on seven operational activities. The facility complied with selected standards in the construction safety activity. The facility’s reported accomplishments were the positive effect of the Systems Redesign Program for clinical and administrative operations, Compensation and Pension Program improvements, and contributions of the Center for Neuroscience and Regeneration/Neurorehabilitation Research. OIG made recommendations for improvement in the following six activities: (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, and (6) nurse staffing.