The purpose of the review was to evaluate selected operations, focusing on patient care administration and quality management (QM). During the review, OIG provided crime awareness briefings to 248 employees. This review focused on 10 operational activities. The facility complied with selected standards in the following five activities: (1) coordination of care, (2) medication management, (3) mental health treatment continuity, (4) nurse staffing, and (5) QM. The facility’s reported accomplishments were an expansion of telemental health services across the Veterans Integrated Service Network and fluorescent gel monitoring to improve terminal cleaning and promote infection control. OIG made recommendations for improvement in the following five activities: (1) colorectal cancer screening, (2) environment of care, (3) moderate sedation, (4) point-of-care testing, and (5) polytrauma.