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 181 employees. This review focused on nine operational activities. The facility complied with selected standards in the following five activities: (1) environment of care, (2) coordination of care – hospice and palliative care, (3) preventable pulmonary embolism, (4) Mental Health Residential Rehabilitation Treatment Program, and (5) continuity of care. The facility’s reported accomplishment was the creation of the VA Pacific Islands Call Center to enhance veterans’ ability to contact the facility. OIG made recommendations for improvement in the following four activities: (1) quality management, (2) medication management – controlled substances inspections, (3) long-term home oxygen therapy, and (4) nurse staffing.