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 234 employees. This review focused on seven operational activities. The facility complied with selected standards in the following four activities: (1) quality management, (2) environment of care, (3) coordination of care – hospice and palliative care, and (4) nurse staffing. The facility’s reported accomplishment was the implementation of interventions to reduce central line infections. OIG made recommendations for improvement in the following three activities: (1) medication management – controlled substances inspections, (2) long-term home oxygen therapy, and (3) preventable pulmonary embolism.