| Home Interior |
Yes |
No |
| Stairs inside home are safe |
| End of stairs is clearly marked (top and
bottom) |
| Handrails on both sides of stairs |
| Hallways and doorways wide and
obstruction free |
| Fire extinguisher available |
| Smoke detectors present |
| Adequate lighting |
| Throw rugs absent |
| Area rugs secure and safe |
| Adequate heat |
| Adequate cooling |
| Space heaters safe |
| Hazardous materials stored safely |
| Adequate plumbing |
| Absence of rodents/insects |
| Adequate trash pickup |
| Space free of clutter/debris |
| Electrical cords safe |
| Safe use of electrical circuits/extension
cords |
| Furniture arranged to facilitate
mobility |
| Furniture appears sturdy and in good
repair |
| Non-carpeted floors are not slippery |
| Door thresholds safe |
| Safe water temperature |
| . |
| Safe Storage of
Chemicals |
Yes |
No |
Caregiver |
| Able to distinguish between products |
| Chemicals stored away from food |
| Outdated products safely disposed |
| Flammables kept away from heat |
| . |
| Exterior |
Yes |
No |
Caregiver |
| Able to get in/out of front door
safely |
| Able to get in/out rear door |
| Able to retrieve mail/newspapers |
| Ramp available, if needed |
| Stairs safe and in good repair |
| Railing on stairs |
| Proper lighting |
| Snow/ice removal, when needed |
| . |
| Bathroom |
Yes |
No |
Caregiver |
| Able to get into bathroom |
| Able to turn on light |
| Able to get on/off commode |
| Able to safely transfer in/out of tub or
shower |
| Able to use faucets |
| Soap available |
| Safe use of transfer bench |
| Night light, if needed |
| Grab bars available and secure |
| Raised toilet seat, if needed |
| Non-slip mat or strips in tub or
shower |
| Proper disposal of soiled incontinence
pads |
| Adequate cleaning/sanitizing |
| . |
| Kitchen |
Yes |
No |
Caregiver |
| Adequate food storage |
| Able to recognize if stove/oven is
on |
| Able to feel heat |
| Fire extinguisher available |
| Smoke detectors present |
| Able to prepare meal |
| Able to operate microwave |
| Able to get groceries |
| Frequently used items within reach |
| . |
| Pet Care |
Yes |
No |
Caregiver |
| Pets safe underfoot |
| Able to feed pets |
| Able to let pet outside |
| Able to change litter box |
| Able to provide pet adequate
exercise |
| . |
| Bedroom |
Yes |
No |
Caregiver |
| Able to get in and out of bed |
| Room for hospital bed, if needed |
| Light accessible |
| Phone accessible from bed |
| Emergency alert system accessible from
bed |
| Adequate heat |
| Bedside commode |
| Flashlight available |
| Night light, if needed |
| . |
| Mobility |
Yes |
No |
Caregiver |
| Absence of falls |
| Balance stable |
| Able to maneuver assistive device |
| Activity tolerance |
| Shoes are safe and comfortable |
| . |
| Communication |
Yes |
No |
Caregiver |
| Able to utilize telephone |
| Emergency response system available |
| Able to use system |
| Can call for help in emergency |
| Able to exit in emergency |
| Able to clearly communicate needs |
| Able to hear alarms |
| . |
| Personal Safety |
Yes |
No |
Caregiver |
| Safe clothing for ambulation and
circulation |
| Wears shoes or non-skid socks inside |
| Able to self-manage medications |
| Safe storage of medications |
| Able to manage thermostat |
| Able to verbalize and enact emergency
plan |
| . |
| Oxygen Care |
Yes |
No |
Caregiver |
| No smoking around oxygen |
| Able to safely change/refill tanks, as
needed |
| Tubing does not obstruct safe
ambulation |