Intentional neglect is the knowing withholding of basic life-sustaining services for a vulnerable older adult with the willing intent to inflict harm. To rise to the level of criminality the following basic elements of a case are present: (1) the perpetrator has acknowledged their duty of care to the victim (2) the perpetrator acts with criminal negligence, recklessness, or intent (3) the perpetrator’s failure to provide care causes death, harm, or an imminent risk of harm to the victim (4) the victim is dependent on the perpetrator for the basic necessities of life. The similarity between some normal changes of aging with physical findings suggestive of neglect make it difficult to draw a straight line to culpability and to therefore prosecute cases. Careful fact gathering and assessment of multiple aspects of the neglected individual’s presentation can improve professional’s level of suspicion that intent to harm was present. Using a multidisciplinary, coordinated community approach to create a full mosaic of the victim’s situation is crucial. Reporting to APS and criminal justice professionals when suspicion for criminality is high is critical to protect the rights of older adults in our community.