Purpose: Making choices about everyday activities is a normal event for many adults. However, when an adult moves into an assisted living (AL) community, making choices becomes complicated by perceived needs and community practices. This study examines the relationship between choice and need in the context of practices, using medication administration practices as the case in point. Design and Methods: A 5-year ethnographic study collected information from 6 AL settings in Maryland. Ethnographic interviews (n = 323) and field notes comprise the data described in this article. Results: AL organizations used practice rationales based on state regulations, professional responsibility, safety concerns, and social model values to describe and explain their setting-specific practices. The result was varying levels of congruence between the setting's practices and individual resident's needs and choices. That is, in some cases, the resident's needs were lost to the organization's practices, and in other cases, organizations adapted to resident need and choices. These findings suggest that individuals and organizations adapt to each other, resulting in practices that are not bound by state requirement or other practice rationales. Implications: AL residences vary due to both internal and external forces, not just the public policies that define them. State regulations need to be responsive to both the needs and the choices of individual residents and to the people who work in an AL.