Run Home Fall Risk Assessment and Prevention Plan — Free

Inspection Setup and Resident Context

Inspection date, location, and inspector recorded

Document the home address or unit identifier, date of visit, and inspector name/role.

Reason for assessment documented

Select the primary reason for the home fall risk assessment.

Mobility aid use and baseline ambulation status documented

Record current mobility supports used in the home.

Note (optional)

Recent fall history reviewed critical (required)

Confirm whether falls, near-falls, or loss of balance in the past 12 months were reviewed.

Yes No N/A

General Home Environment Hazards

Walkways and common paths are free of clutter critical (required)

Inspect hallways, entry paths, and frequently used routes for boxes, cords, shoes, and other tripping hazards.

Yes No N/A

Photo evidence (optional)

Floor surfaces are dry, even, and free of loose rugs critical (required)

Check for wet floors, uneven transitions, curled edges, unsecured mats, and loose throw rugs.

Yes No N/A

Photo evidence (optional)

Lighting is adequate in all frequently used areas

Measure or estimate light level in key walking areas; note if additional lighting is needed.

Electrical cords and hoses are secured away from walking paths critical (required)

Verify that extension cords, charging cables, and hoses do not cross or obstruct walkways.

Yes No N/A

Photo evidence (optional)

Pets and pet items do not create trip hazards

Check for pet bowls, toys, beds, or animals in pathways that could contribute to falls.

Yes No N/A

Room-by-Room Safety Check

Bathroom has grab bars or other stable support near toilet and shower/tub critical (required)

Assess whether stable support is present where transfers are performed.

Yes No N/A

Photo evidence (optional)

Bathroom floor and shower/tub surfaces are non-slip critical (required)

Verify presence of non-slip mats or adhesive strips and absence of slick surfaces.

Yes No N/A

Photo evidence (optional)

Bedroom path to bathroom is clear and accessible critical (required)

Inspect the route from bed to bathroom for obstacles, poor lighting, or narrow clearances.

Yes No N/A

Photo evidence (optional)

Stairs, steps, and thresholds are marked and in good condition critical (required)

Check handrails, step edges, threshold height, and visibility of transitions.

Yes No N/A

Photo evidence (optional)

Kitchen and laundry areas are free of spill and reach hazards

Look for wet floors, frequently used items stored too high or too low, and unstable step stools.

Yes No N/A

Mobility, Transfer, and Assistive Device Safety

Assistive device is present, appropriate, and in good condition critical (required)

Confirm that cane, walker, or other device matches current needs and shows no visible damage or instability.

Yes No N/A

Photo evidence (optional)

Footwear is supportive and appropriate for indoor use

Verify that the resident uses well-fitting shoes or non-slip footwear rather than socks or loose slippers.

Yes No N/A

Transfer technique and need for assistance reviewed

Document whether transfers were observed or discussed and whether assistance is required.

Note (optional)

Patient Education and Prevention Plan

Fall prevention education provided critical (required)

Select all education topics reviewed with the resident and/or caregiver.

Note (optional)

Home modifications or interventions recommended critical (required)

Document specific recommendations such as removing loose rugs, adding grab bars, increasing lighting, or rearranging furniture.

Follow-up plan established critical (required)

Record follow-up date, responsible party, and any referrals (e.g., PT/OT, primary care, home safety resources).

Findings, Corrective Actions, and Sign-Off

Deficiencies documented with corrective actions critical (required)

Summarize all observed deficiencies, the associated risk, and the corrective action plan.

Inspector signature critical (required)

Inspector attests that the assessment was completed and findings are accurate.

Resident or caregiver acknowledgment

Capture acknowledgment of education and recommended prevention actions when applicable.

Note (optional)

Get your results

Enter your email — we'll send you a PDF of your filled-out template, plus the occasional MangoScoop newsletter (templates, workflow tips, product updates). Unsubscribe anytime — link is in every email.

Email (required)

Your name (optional)

Run: Home Fall Risk Assessment and Prevention Plan

Inspection Setup and Resident Context

General Home Environment Hazards

Room-by-Room Safety Check

Mobility, Transfer, and Assistive Device Safety

Patient Education and Prevention Plan

Findings, Corrective Actions, and Sign-Off

Get your results