Purpose: The objective of this study was to identify gaps in and to improve the falls prevention strategy (FPS) of an inpatient rehabilitation facility (IRF) in Toronto, Canada. Design: A modified version of the Stanford Biodesign Methodology was used. Methods: Chart reviews, a focus group (n = 8), and semistructured interviews (n = 8) were conducted to evaluate the FPS. Findings: Admission Functional Independence Measure score, age, and gender significantly correlated with risk for a fall. The tool used at this IRF was not effectively capturing patients who were at high risk for falls. All healthcare providers interviewed were knowledgeable of fall risks; however, a patient's fall risk status was rarely discussed as a team. Conclusions: The findings informed recommendations to improve the overall FPS at this IRF. Clinical Relevance: Staff may require more coaching for implementing preventative measures/ensuring accountability and evaluating whether current strategies work. These insights can guide improvement initiatives at similar facilities elsewhere.