The OIG conducted an inspection to determine the validity of allegations regarding pharmacy response, surgical and mental health consultant response times, nurse staffing, deep dives, and inadequate leadership communication regarding proposed changes at the VA Illiana Health Care System (HCS) (facility) in Danville, IL. We substantiated that the Mental Health Service did not respond to “emergency,” “within one hour,” and “within 24 hour” consults for patients diagnosed with suicidal ideation within facility policy timeframes. Patients, however, are kept on a one-to-one observation basis until evaluated and cleared by a psychiatrist. We also substantiated that registered nurses were assigned to units without the required competencies validated as required by The Joint Commission. We did not substantiate that Surgical and Pharmacy Services are not providing timely services as required by the Veterans Health Administration directives and facility policy, or that nursing leadership was deficient in its staffing plans. However, we did substantiate that nurse staffing on two units did not comply with unit staffing plans. We also did not substantiate that punitive action was taken against an employee based on results of a deep dive facility review, or that facility leadership has not communicated with staff proposed changes. The Veterans Integrated Service Network and Facility Directors agreed with our findings and four recommendations and provided acceptable improvement plans.