Tim is a 79-year-old man with moderate to severe Alzheimer’s disease who was admitted from his home to a rural nursing home for long-term care. Tim is fit and slim, walks well with good balance, and is able to do his activities of daily living with some supervision. Tim is also a “wanderer,” is hard of hearing, and is very confused about where he is. Three days after he was admitted Tim was found missing from his room when the nursing assistant brought dinner. On this particular cold, dark, and foggy evening there were three nursing assistants and one licensed vocational nurse on duty (acting as the charge nurse). In addition, there was one physical therapist working late to finish up on the day’s paperwork. The facility had 51 residents, some of whom had moderate to severe dementia, plus eight acute rehab patients.