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 112 employees. This review focused on 10 operational activities. The facility complied with selected standards in the following three activities: (1) colorectal cancer screening (2) medication management, and (3) QM. The facility’s reported accomplishments were leadership and structural changes and hosting the 2012 National Veterans Golden Age Games. OIG made recommendations for improvement in the following seven activities: (1) environment of care, (2) moderate sedation, (3) mental health treatment continuity, (4) nurse staffing, (5) polytrauma, (6) point-of-care testing, and (7) coordination of care.