This article documents the change management process undertaken in a small community hospital on one stage of the journey toward a patient safety culture. On this part of the journey, the patient care model founded on a philosophy of falls prevention was transformed to one based on a model of falls management. The change process culminated in a more elder-friendly environment complemented by a respect for patients' choices, even when those choices include personal risk. Our cultural transformation resulted in a patient safety culture characterized by (1) a restraints-free physical environment and (2) a rate of patient falls accompanied by serious harm that is lower than the industry average. The first step on our journey to a culture of patient safety was completed over a three-year period.