Form Fire & Safety Surv Fire & Safety Surv CMS-2786R

2000 CODE

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

FIRE SAFETY SURVEY REPORT 2000 CODE - HEALTH CARE
Medicare – Medicaid

1. (A) PROVIDER NUMBER

1. (B) MEDICAID I.D. NO.

K1

K2

Form Approved
OMB No. 0938-0242

PART I — Life & Safety Code, New and Existing
PART IV — Waiver Recommendation Form
Identifying information as shown in applicable records. Enter changes, if any, alongside each item, giving date of change.
2. NAME OF FACILITY

2. (A) MULTIPLE CONSTRUCTION (BLDGS)

2. (B) ADDRESS OF FACILITY (STREET, CITY, STATE, ZIP CODE) A.

A. BUILDING ________________
B. WING

________________

C. FLOOR

________________

B.

■ MEDICARE

■

■ Partially Sprinklered
(Not all required areas are sprinklered)

C.

K3

3. SURVEY FOR

Sprinklered
■ Fully
(All required areas are sprinklered)

■ None (No sprinkler system)

K0180

4. DATE OF SURVEY

DATE OF PLAN APPROVAL

K4

K6

SURVEY UNDER
5.

MEDICAID

■ 2000 EXISTING

6.

■ 2000 NEW

K7

5. SURVEY FOR CERTIFICATION OF
1.

■ HOSPITAL

2.

■

SKILLED/NURSING FACILITY

4.

■

ICF/MR UNDER HEALTH CARE

5.

■

HOSPICE

K5

IF “2” OR “5” ABOVE IS MARKED, CHECK APPROPRIATE ITEM(S) BELOW
1.

■ ENTIRE FACILITY

6. BED COMPOSITION
a. TOTAL NO. OF BEDS
IN THE FACILITY _______

2.

3.

■ DISTINCT PART OF (SPECIFY)_________________________________
b. NUMBER OF HOSPITAL BEDS
CERTIFIED FOR MEDICARE ____

c. NUMBER OF SKILLED BEDS
CERTIFIED FOR MEDICARE ______

■ THE FACILITY MEETS, BASED UPON (CHECK ALL APPROPRIATE BOXES)
1. ■ COMPLIANCE WITH ALL PROVISIONS 2. ■ ACCEPTANCE OF A PLAN OF CORRECTION
B. ■ THE FACILITY DOES NOT MEET THE STANDARD

DISTINCT PART OF HOSPITAL, IS HOSPITAL ACCREDITED BY
■ IFJCAHO/AOA?
a. ■ YES
b. ■ NO

d. NUMBER OF SKILLED BEDS
e. NUMBER OF NF or ICF/MR BEDS
CERTIFIED FOR MEDICAID ______
CERTIFIED FOR MEDICAID _______

7. A.

K9

SURVEYOR (Signature)

3.

■ RECOMMENDED WAIVERS

4.

■ FSES

5.

■ PERFORMANCE BASED DESIGN

TITLE

OFFICE

DATE

TITLE

OFFICE

DATE

SURVEYOR ID
K10

FIRE AUTHORITY OFFICIAL (Signature)

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for
this information collection is 0938-0242. The time required to complete this information collection is estimated to average 5 minutes per response, including the time to review instructions, search existing
data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this
form, please write to CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.
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Name of Facility

2000 CODE

ID
PREFIX

MET NOT
MET

N/A

REMARKS

PART I - LSC REQUIREMENTS - Items in italics relate to the FSES

BUILDING CONSTRUCTION
K11

If the building has a common wall with a nonconforming building,
the common wall is a fire barrier having at least a two hour fire
resistance rating constructed of materials as required for the
addition. Communicating openings occur only in corridors and
shall be protected by approved self-closing fire doors.
18.1.1.4.1, 18.1.1.4.2, 19.1.1.4.1, 19.1.1.4.2

K12

2000 EXISTING
Building construction type and height meets one of the following:
19.1.6.2, 19.1.6.3, 19.1.6.4, 19.3.5.1

TA9

1

I (443), I (332), II (222)

Any Height

2

II (111)

One story only
(non-sprinklered).

3

II (111)

Not over three stories with
complete automatic
sprinkler system.

4

III (211)

5

V (111)

6

IV (2HH)

7

II (000)

8

III (200)

9

V (000)

Not over two stories with
complete automatic
sprinkler system.

Not over one story with
complete automatic
sprinkler system.

■ Building contains fire treated wood.
Give a brief description, in REMARKS, of the construction, the number
of stories, including basements, floors on which patients are located,
location of smoke or fire barriers and dates of approval. Complete
sketch or attach small floor plan of the building as appropriate.
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2000 CODE

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K12

MET NOT
MET

N/A

REMARKS

2000 NEW
Building construction type and height meets one of the following:
18.1.6.2, 18.1.6.3, 18.2.5.1

K13
1

I (443), I (332), II (222)

Any height with complete
automatic sprinkler system

2

II (111)

Not over three stories
with complete automatic
sprinkler system

3

III (211)

4

V (111)

5

IV (2HH)

6

II (000)

7

III (200)

8

V (000)

Not over one story with
complete automatic
sprinkler system.

Not Permitted

■ Building contains fire treated wood.
Give a brief description, in REMARKS, of the construction, the
number of stories, including basements, floors on which patients
are located, location of smoke or fire barriers and dates of
approval. Complete sketch or attach small floor plan of the
building as appropriate.
K103 Interior walls and partitions in buildings of Type I or Type II
construction shall be noncombustible or limited-combustible
materials. 18.1.6.3, 19.1.6.3
(Indicate N/A for existing buildings using listed fire retardant
treated wood studs within non-load bearing one-hour rated
partitions.)
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2000 CODE

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N/A

REMARKS

INTERIOR FINISH
K14

2000 EXISTING
Interior finish for corridors and exitways, including exposed
interior surfaces of buildings such as fixed or movable walls,
partitions, columns, and ceilings has a flame spread rating of
Class A or Class B. 19.3.3.1, 19.3.3.2

Indicate flame spread rating/s _________
2000 NEW
Interior finish for corridors and exitways, including exposed
interior surfaces of buildings such as fixed or movable walls,
partitions, columns, and ceilings has a flame spread rating of
Class A or Class B. Lower portion of corridor walls can be
Class C. 18.3.3.1, 18.3.3.2

Indicate flame spread rating/s_________
K15

2000 EXISTING
Interior finish for rooms and spaces not used for corridors or
exitways, including exposed interior surfaces of buildings such
as fixed or movable walls, partitions, columns, and ceilings has
a flame spread rating of Class A or Class B. (In fully-sprinklered
buildings, flame spread rating of Class A, Class B, or Class C
may be continued in use within rooms separated in accordance
with 19.3.6 from the access corridors.) 19.3.3.1, 19.3.3.2

Indicate flame spread rating/s_________
2000 NEW
Interior finish for rooms and spaces not used for corridors or
exitways, including exposed interior surfaces of buildings such
as fixed or movable walls, partitions, columns, and ceilings has
a flame spread rating of Class A or Class B. (Rooms not over
4 persons in capacity may have a flame spread rating of Class A,
Class B, or Class C). 18.3.3.1, 18.3.3.2.

Indicate flame spread rating/s_________
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2000 CODE

ID
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K16

MET NOT
MET

N/A

REMARKS

Newly installed interior floor finish complying with 10.2.7 shall be
permitted in corridors and exits if Class I. 18.3.3.3, 19.3.3.3
(Indicate N/A for existing interior floor finish.)
In smoke compartments protected throughout by an approved,
supervised automatic sprinkler system in accordance with
19.3.5.2, no interior floor finish requirements shall apply.
CORRIDOR WALLS AND DOORS

K17

2000 EXISTING
Corridors are separated from use areas by walls constructed with
at least 1/2 hour fire resistance rating. In fully sprinklered smoke
compartments, partitions are only required to resist the passage
of smoke. In non-sprinklered buildings, walls properly extend
above the ceiling. (Corridor walls may terminate at the underside
of ceilings where specifically permitted by Code. Charting and
clerical stations, waiting areas, dining rooms, and activity spaces
may be open to corridor under certain conditions specified in the
Code. Gift shops may be separated from corridors by non-fire
rated walls if the gift shop is fully sprinklered.)
19.3.6.1, 19.3.6.2.1, 19.3.6.5

If the walls have a fire resistance rating, give rating_________
if the walls terminate at the underside of a ceiling, give a brief
description in REMARKS, of the ceiling, describing the ceiling
throughout the floor area.
2000 NEW
Corridor walls shall form a barrier to limit the transfer of smoke.
Such walls shall be permitted to terminate at the ceiling where
the ceiling is constructed to limit the transfer of smoke. No fire
resistance rating is required for the corridor walls.
18.3.6.1, 18.3.6.2, 18.3.6.5

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2000 CODE

ID
PREFIX

K18

MET NOT
MET

N/A

REMARKS

2000 EXISTING
Doors protecting corridor openings in other than required
enclosures of vertical openings, exits, or hazardous areas shall
be substantial doors, such as those constructed of 13/4 inch
solid-bonded core wood, or capable of resisting fire for at least
20 minutes. Doors in fully sprinklered smoke compartments are
only required to resist the passage of smoke. There is no
impediment to the closing of the doors. Doors shall be provided
with a means suitable for keeping the door closed. Dutch doors
meeting 19.3.6.3.6 are permitted. 19.3.6.3 Roller latches are
prohibited by CMS regulations in all health care facilities.

Show in REMARKS, details of doors, such as fire protection
ratings, automatic closing devices, etc.
2000 New
Doors protecting corridor openings shall be constructed to resist
the passage of smoke. Doors shall be provided with positive
latching hardware. Dutch doors meeting 18.3.6.3.6 are permitted.
Roller latches shall be prohibited. 18.3.6.3

Show in REMARKS, details of doors, such as fire protection
ratings, automatic closing devices, etc.
K19

Vision panels in corridor walls or doors shall be fixed window
assemblies in approved frames. (In fully sprinklered smoke
compartments, there are no restrictions in the area and fire
resistance of glass and frames.)
18.3.6.5, 18.3.6.3.1, 19.3.6.2.3, 19.3.6.3.8, 19.3.6.5

K22

Access to exits shall be marked by approved, readily visible
signs in all cases where the exit or way to reach exit is not
readily apparent to the occupants. 7.10.1.4
VERTICAL OPENINGS

K20

2000 EXISTING
Stairways, elevator shafts, light and ventilation shafts, chutes,
and other vertical openings between floors are enclosed with
construction having a fire resistance rating of at least one hour.
An atrium may be used in accordance with 8.2.5.6, 19.3.1.1

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Name of Facility
ID
PREFIX

2000 CODE
MET NOT
MET

N/A

REMARKS

If all vertical openings are properly enclosed with construction
providing at least a two hour fire resistance rating, also check
this box. ■
If enclosures are less than required, give a brief description and
specific location in REMARKS.
2000 NEW
Stairways, elevator shafts, light and ventilation shafts, chutes,
and other vertical openings between floors are enclosed with
construction having a fire resistance rating of at least two hours
connecting four stories or more. (One hour for single story
building and sprinklered buildings up to three stories in height.)
18.3.1.1. An atrium may be used in accordance with 8.2.2.3.5.

If enclosures are less than required, give a brief description and
specific location in REMARKS.
K21

Any door in an exit passageway, stairway enclosure, horizontal
exit, smoke barrier or hazardous area enclosure shall be
permitted to be held open only by devices arranged to
automatically close all such doors by zone or throughout the
facility upon activation of:
■ (a) The required manual fire alarm system and
■ (b) Local smoke detectors designed to detect smoke
passing through the opening or a required smoke
detection system and
■ (c) The automatic sprinkler system, if installed
18.2.2.2.6, 19.2.2.2.6, 7.2.1.8.2
Describe method used in REMARKS

K33

2000 EXISTING
Exit components (such as stairways) are enclosed with
construction having a fire resistance rating of at least one hour,
are arranged to provide a continuous path of escape, and
provide protection against fire or smoke from other parts of the
building. 8.2.5.2, 19.3.1.1

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Name of Facility
ID
PREFIX

2000 CODE
MET NOT
MET

N/A

REMARKS

If all vertical openings are properly enclosed with construction
providing at least a two hour fire resistance rating, also check
this box. ■
If enclosures are less than required, give a brief description and
specific location in REMARKS.
2000 NEW
Exit components (such as stairways) in buildings four stories or
more are enclosed with construction having a fire resistance
rating of at least two hours, are arranged to provide a continuous
path of escape, and provide a protection against fire and smoke
from other parts of the building. In all buildings less than four
stories, the enclosure is at least one hour. 8.2.5.4, 18.3.1.1

If enclosures are less than required, give a brief description and
specific location in REMARKS.
SMOKE COMPARTMENTATION AND CONTROL
K23

2000 EXISTING
Smoke barriers shall be provided to form at least two smoke
compartments on every sleeping room floor for more than 30
patients. 19.3.7.1, 19.3.7.2
2000 NEW
Smoke barriers shall be provided to form at least two smoke
compartments on every floor used by inpatients for sleeping or
treatment, and on every floor with an occupant load of 50 or
more persons, regardless of use. Smoke barriers shall also be
provided on floors that are usable, but unoccupied. 18.3.7.1,
18.3.7.2

K24

The smoke compartments shall not exceed 22,500 square feet and
the travel distance to and from any point to reach a door in the
required smoke barrier shall not exceed 200 feet. 18.3.7.1, 19.3.7.1

Detail in REMARKS zone dimensions including length of zones
and dead end corridors.

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ID
PREFIX

K25

2000 CODE
MET NOT
MET

N/A

REMARKS

2000 EXISTING
Smoke barriers shall be constructed to provide at least a onehalf hour fire resistance rating and constructed in accordance
with 8.3. Smoke barriers shall be permitted to terminate at an
atrium wall. Windows shall be protected by fire-rated glazing or
by wired glass panels and steel frames. A minimum of two
separate compartments shall be provided on each floor.
Dampers shall not be required in duct penetrations of smoke
barriers in fully ducted heating, ventilating, and air conditioning
systems.19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4
2000 NEW
Smoke barriers shall be constructed to provide at least a onehour fire resistance rating and constructed in accordance with
8.3. Smoke barriers shall be permitted to terminate at an atrium
wall. Windows shall be protected by fire-rated glazing or by
wired glass panels in approved frames. A minimum of two
separate compartments shall be provided on each floor.
Dampers shall not be required in duct penetrations of smoke
barriers in fully ducted heating, ventilating, and air conditioning
systems. 18.3.7.3, 18.3.7.5, 18.1.6.3

K26

Space shall be provided on each side of smoke barriers to
adequately accommodate those occupants served. 18.3.7.4, 19.3.7.4

K27

2000 EXISTING
Door openings in smoke barriers have at least a 20 minute fire
protection rating or are at least 13/4 inch thick solid bonded core
wood. Non-rated protective plates that do not exceed 48 inches
from the bottom of the door are permitted. Horizontal sliding
doors comply with 7.2.1.14. Doors shall be self-closing or
automatic-closing in accordance with 19.2.2.2.6. Swinging doors
are not required to swing with egress and positive latching is not
required. 19.3.7.5, 19.3.7.6, 19.3.7.7
2000 NEW
Door openings in smoke barriers have at least a 20 minute fire
protection rating or are at least 13/4 inch thick solid bonded core wood.
Non-rated protective plates that do not exceed 48 inches from the
bottom of the door are permitted. Horizontal sliding doors comply with
7.2.1.14. Swinging doors shall be arranged so that each door swings
in an opposite direction. Doors shall be self-closing and rabbets,
bevels or astragals are required at the meeting edges. Positive
latching is not required. 18.3.7.5, 18.3.7.6, 18.3.7.8

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2000 CODE

ID
PREFIX

K28

MET NOT
MET

N/A

REMARKS

2000 EXISTING
Door openings in smoke barriers shall provide a minimum clear
width of 32 inches (81 cm) for swinging or horizontal doors.
Vision panels are of fire-rated glazing or wired glass panels and
steel frames. 19.3.7.5, 19.3.7.7
2000 NEW
Door openings in smoke barriers are installed as swinging or
horizontal doors shall provide a minimum clear width as follows:
Provider Type

Swinging Doors

Horizontal Sliding Doors

Hospitals and
Nursing Facilities

41.5 inches
(105 cm)

83 inches
(211 cm)

Psychiatric Hospitals and
Limited Care Facilities

32 inches
(81 cm)

64 inches
(163 cm)

Vision panels of fire-rated glazing or wired panels in approved
frames are provided for each door. 18.3.7.5, 18.3.7.7
K104

Penetrations of smoke barriers by ducts are protected in
accordance with 8.3.6.
Describe any mechanical smoke control system in REMARKS.
HAZARDOUS AREA

K29

2000 EXISTING
One hour fire rated construction (with 3/4 hour fire-rated doors) or
an approved automatic fire extinguishing system in accordance
with 8.4.1 and/or 19.3.5.4 protects hazardous areas. When the
approved automatic fire extinguishing system option is used, the
areas shall be separated from other spaces by smoke resisting
partitions and doors. Doors shall be self-closing and non-rated or
field-applied protective plates that do not exceed 48 inches from
the bottom of the door are permitted. 19.3.2.1
Area
Automatic Sprinkler
a. Boiler and Fuel-Fired Heater Rooms
c. Laundries (greater than 100 sq feet)
d. Repair Shops and Paint Shops
e. Laboratories (if classified a Severe Hazard - see K31)
f. Combustible Storage Rooms/Spaces (over 50 sq feet)
g. Trash Collection Rooms
i. Soiled Linen Rooms

Separation

N/A

Describe the floor and zone locations of hazardous areas that
are deficient in REMARKS.
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2000 CODE

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N/A

REMARKS

2000 NEW
Hazardous areas are protected in accordance with 8.4. The
areas shall be enclosed with a one hour fire-rated barrier, with a
3
/4 hour fire-rated door, without windows (in accordance with 8.4).
Doors shall be self-closing or automatic closing in accordance
with 7.2.1.8. 18.3.2.1
Area
Automatic Sprinkler
a. Boiler and Fuel-Fired Heater Rooms
c. Laundries (greater than 100 sq feet)
d. Repair, Maintenance and Paint Shops
e. Laboratories (if classified a Severe Hazard - see K31)
f. Combustible Storage Rooms/Spaces
(over 50 and less than 100 sq feet)
g. Trash Collection Rooms
i. Soiled Linen Rooms
m.Combustible Storage Rooms/Spaces (over 100 sq feet)

Separation

N/A

Describe the floor and zone locations of hazardous areas that
are deficient in REMARKS.
K30

Gift shops shall be protected as hazardous areas when used for
storage or display of combustibles in quantities considered
hazardous. Non-rated walls may separate gift shops that are not
considered hazardous, have separate protected storage and that
are completely sprinkled. Gift shops may be open to the corridor
if they are not considered hazardous, have separate protected
storage, are completely sprinklered and do not exceed 500
square ºfeet. 18.3.2.5, 19.3.2.5
Area
L. Gift Shop storing hazardous quantities
of combustibles

K211

Automatic Sprinkler

Separation

N/A

2000 EXISTING
Where Alcohol Based Hand Rub (ABHR) dispensers are
installed:
❏ The corridor is at least 6 feet wide
❏ The maximum individual fluid dispenser capacity shall be
1.2 liters (2 liters in suites of rooms)
❏ The dispensers shall have a minimum spacing of 4 ft from
each other
❏ Not more than 10 gallons are used in a single smoke
compartment outside a storage cabinet.
❏ Dispensers are not installed over or adjacent to an ignition
source.
❏ If the floor is carpeted, the building is fully sprinklered. 19.3.2.7,
CFR 403.744, 418.100, 460.72, 482.41, 483.70, 483.623, 485.623

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2000 CODE

ID
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K211

MET NOT
MET

N/A

REMARKS

2000 NEW
Where Alcohol Based Hand Rub (ABHR) dispensers are
installed:
❏ The corridor is at least 6 feet wide
❏ The maximum individual fluid dispenser capacity shall be
1.2 liters (2 liters in suites of rooms)
❏ The dispensers shall have a minimum spacing of 4 ft from
each other
❏ Not more than 10 gallons are used in a single smoke
compartment outside a storage cabinet.
❏ Dispensers are not installed over or adjacent to an ignition
source.
❏ If the floor is carpeted, the building is fully sprinklered. 18.3.2.7,
CFR 403.744, 418.100, 460.72, 482.41, 483.70, 483.623, 485.623
EXIT AND EXIT ACCESS

K32

Not less than two exits, remote from each other, are provided
for each floor or fire section of the building. Only one of these
two exits may be a horizontal exit. 18.2.4.1, 18.2.4.2, 19.2.4.1,
19.2.4.2
EXITS AND EGRESS

K34

Stairways and smokeproof towers used as exits are in
accordance with 7.2.
18.2.2.4, 19.2.2.3, 19.2.2.4

K35

Capacity of exits in number of persons per unit of exit width is in
accordance with 7.3.
18.2.3.1, 19.2.3.1

K36

Travel distance (exit access) to exits are in accordance with 7.6.
18.2.6, 19.2.6

K37

2000 EXISTING
Existing dead-end corridors shall be permitted to be continued to
be used if it is impractical and unfeasible to alter them so that
exists are accessible in not less than two different directions
from all points in aisles, passageways, and corridors. 19.2.5.10

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2000 CODE
MET NOT
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N/A

REMARKS

2000 NEW
Every exit and exit access shall be arranged so that no
corridor, aisle or passageway has a pocket or dead-end
exceeding 30 feet. 18.2.5.10
K38

Exit access is so arranged that exits are readily accessible at all
times in accordance with 7.1.
18.2.1, 19.2.1

K39

2000 EXISTING
Width of aisles or corridors (clear and unobstructed) serving as
exit access shall be at least 4 feet. 19.2.3.3
2000 NEW
Width of aisles or corridors (clear and unobstructed) serving as
exit access in hospitals and nursing homes shall be at least 8
feet. In limited care facility and psychiatric hospitals, width of
aisles or corridors shall be at least 6 feet. 18.2.3.3, 18.2.3.4

K40

2000 EXISTING
Exit access doors and exit doors used by health care occupants
are of the swinging type and are at least 32 inches in clear width.
19.2.3.5
2000 NEW
Exit access doors and exit doors used by health care occupants
are of the swinging type, with openings of at least 41.5 inches
wide. Doors in exit stairway enclosures shall be no less than 32
inches in clear width. In ICFs/MR, doors are at least 32 inches
wide. 18.2.3.5

K41

All sleeping rooms have a door leading to a corridor providing
access to an exit or have a door leading directly to grade. One
room may intervene in accordance with 18.2.5.1, 19.2.5.1,
18.2.5.9, 19.2.5.9

If doors lead directly to grade from each room, check this box. ■
K42

Any room or suite of rooms of more than 1,000 sq. ft. has at least
2 exit access doors remote from each other. 18.2.5.2, 19.2.5.2

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2000 CODE

ID
PREFIX

K43

MET NOT
MET

N/A

REMARKS

Patient room doors are arranged such that the patients can open
the door from inside without using a key.
Special door locking arrangements are permitted in facilities.
18.2.2.2.4, 18.2.2.2.5

If door locking arrangement without delay egress is used
indicate in REMARKS
18.2.2.2.2, 19.2.2.2.2
K44

Horizontal exits, if used, are in accordance with 7.2.4.
18.2.2.5, 19.2.2.5
ILLUMINATION AND EMERGENCY POWER

K45

Illumination of means of egress, including exit discharge, is
arranged so that failure of any single lighting fixture (bulb) will
not leave the area in darkness.
18.2.8, 19.2.8, 7.8

K46

Emergency lighting of at least 11/2 hour duration is provided in
accordance with 7.9.
18.2.9.1, 19.2.9.1.

K47

2000 EXISTING
Exit and directional signs are displayed in accordance with 7.10
with continuous illumination also served by the emergency
lighting system.
19.2.10.1
(Indicate N/A in one story buildings with less than 30 occupants
where the line of exit travel is obvious.)
2000 NEW
Exit and directional signs are displayed with continuous
illumination also served by the emergency lighting, system in
accordance with 7.10.
18.2.10.1

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2000 CODE

ID
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K105

MET NOT
MET

N/A

REMARKS

2000 NEW (INDICATE N/A FOR EXISTING)
Buildings equipped with or requiring the use of life support
systems (electro-mechanical or inhalation anesthetics) have
illumination of means of egress, emergency lighting equipment,
exit, and directional signs supplied by the Life Safety Branch of
the electrical system described in NFPA 99. 18.2.9.2., 18.2.10.2,
18.5.1.1, 18.5.1.2
(Indicate N/A if life support equipment is for emergency
purposes only).

K107

2000 NEW (INDICATE N/A FOR EXISTING)
Required alarm and detection systems are provided with an
alternative power supply in accordance with NFPA 72.
9.6.1, 18.3.4.1.3

K108

2000 NEW (INDICATE N/A FOR EXISTING)
Alarms, emergency communication systems, and illumination of
generator set locations are in accordance with NFPA 70. 9.1.2
EMERGENCY PLAN AND FIRE DRILLS

K48

There is a written plan for the protection of all patients and for
their evacuation in the event of an emergency.
18.7.1.1, 19.7.1.1

K50

Fire drills are held at unexpected times under varying conditions,
at least quarterly on each shift. The staff is familiar with
procedures and is aware that drills are part of established routine.
Responsibility for planning and conducting drills is assigned only
to competent persons who are qualified to exercise leadership.
Where drills are conducted between 9:00 PM and 6:00 AM a
coded announcement may be used instead of audible alarms.
18.7.1.2, 19.7.1.2

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Page 15

Name of Facility

2000 CODE

ID
PREFIX

MET NOT
MET

N/A

REMARKS

FIRE ALARM SYSTEMS
K51

2000 EXISTING
A fire alarm system with approved component, devices or
equipment installed according to NFPA 72, National Fire Alarm
Code to provide effective warning of fire in any part of the
building. Activation of the complete fire alarm system shall be by
manual fire alarm initiation, automatic detection or extinguishing
system operation. Pull stations in patient sleeping areas, may
be omitted provided that manual pull stations are within 200 ft of
nurse’s stations. Pull stations are located in the path of egress.
Electronic or written records of tests shall be available. A reliable
second source of power must be provided. Fire alarm systems
shall be in accordance with NFPA72, and records of maintenance
kept readily available. There shall be annunciation of the fire
alarm system to an approved central station. 19.3.4, 9.6
2000 NEW
A fire alarm system with approved component, devices or
equipment installed according to NFPA 72, to provide effective
warning of fire in any part of the building. Activation of the
complete fire alarm system shall be by manual fire alarm initiation,
automatic detection or extinguishing system operation. Pull
stations are located in the path of egress. Electronic or written
records of tests shall be available. A reliable second source of
power must be provided. Fire alarm systems shall be maintained
in accordance with NFPA72, and records of maintenance kept
readily available. There shall be remote annunciation of the fire
alarm system to an approved central station. 18.3.4, 9.6

K52

A fire alarm system required for life safety shall be installed,
tested, and maintained in accordance with NFPA 70 National
Electrical Code and NFPA 72. The system shall have an
approved maintenance and testing program complying with
applicable requirement of NFPA 70 and 72. 9.6.1.4

K155

Where a required fire alarm system is out of service for more
than 4 hours in a 24-hour period, the authority having jurisdiction
shall be notified, and the building shall be evacuated or an
approved fire watch shall be provided for all parties left
unprotected by the shutdown until the fire alarm system has
been returned to service. 9.6.1.8

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Page 16

Name of Facility
ID
PREFIX

K53

2000 CODE
MET NOT
MET

N/A

REMARKS

2000 EXISTING (INDICATE N/A FOR HOSPITAL AND FULLY
SPRINKLERED NURSING HOMES)
In an existing nursing home, not fully sprinklered, the resident
sleeping rooms and public areas (dining rooms, activity rooms,
resident meeting rooms, etc) are to be equipped with single
station battery-operated smoke detectors. There will be a testing,
maintenance and battery replacement program to ensure proper
operation. CFR 483.70
2000 NEW (NURSING HOME AND EXISTING LIMITED
CARE FACILITIES)
An automatic smoke detection system is installed in all corridors.
(As an alternative to the corridor smoke detection system on
patient sleeping room floors, smoke detectors may be installed in
each patient sleeping room and at smoke barrier or horizontal
exit doors in the corridor.) Such detectors are electrically
interconnected to the fire alarm system. 18.3.4.5.3

K109

2000 EXISTING LIMITED CARE FACILITIES
(INDICATE N/A FOR HOSPITALS OR NURSING HOMES)
An automatic smoke detection system is installed in all corridors
with detector spacing no further apart than 30 ft on center in
accordance with NFPA 72. (As an alternative to the corridor
smoke detection system on patient sleeping room floors, smoke
detectors may be installed in each patient sleeping room and at
smoke barrier or horizontal exit doors in the corridors.) Such
detectors are electrically interconnected to the fire alarm system.
19.3.4.5.1
Smoke Detection System
❏ Corridors
❏ Rooms
❏ Bath

K54

All required smoke detectors, including those activating door
hold-open devices, are approved, maintained, inspected and
tested in accordance with the manufacturer’s specifications.
9.6.1.3

Give a brief description, in REMARKS of any smoke detection
system which may be installed.

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Name of Facility

2000 CODE

ID
PREFIX

K55

MET NOT
MET

N/A

REMARKS

2000 EXISTING
Every patient sleeping room shall have an outside window or
outside door. Except for newborn nurseries and rooms intended
for occupancy for less than 24 hours. 19.3.8
2000 NEW
Every patient sleeping room shall have an outside window or
outside door. The allowable sill height shall not exceed 36 inches
(91 cm) above the floor. Windows are not required for recovery
rooms, newborn nurseries, emergency rooms, and similar rooms
intended for occupancy for less than 24 hours. Window sill height
for limited care facilities shall not exceed 44 inches (112 cm)
above the floor. 18.3.8
AUTOMATIC SPRINKLER SYSTEMS

K56

2000 EXISTING
Where required by section 19.1.6, Health care facilities shall be
protected throughout by an approved, supervised automatic
sprinkler system in accordance with section 9.7. Required
sprinkler systems are equipped with water flow and tamper
switches which are electrically interconnected to the building fire
alarm. 19.3.5, NPFA 13
2000 NEW
There is an automatic sprinkler system installed in accordance
with NFPA13, Standard for the Installation of Sprinkler Systems,
with approved components, device and equipment, to provide
complete coverage of all portions of the facility. Systems are
equipped with waterflow and tamper switches, which are
connected to the fire alarm system. 18.3.5.

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Page 18

Name of Facility
ID
PREFIX

K154

2000 CODE
MET NOT
MET

N/A

REMARKS

Where a required automatic sprinkler system is out of service
for more than 4 hours in a 24-hour period, the authority having
jurisdiction shall be notified, and the building shall be evacuated
or an approved fire watch system be provided for all parties left
unprotected by the shutdown until the sprinkler system has been
returned to service. 9.7.6.1.
A. Date sprinkler system last checked and necessary
maintenance provided. _______________________________
B. Show who provided the service. _______________________
C. Note the source of water supply for the automatic
sprinkler system.____________________________________

(Provide, in REMARKS, information on coverage for any
non-required or partial automatic sprinkler system.)
K60

Initiation of the required fire alarm systems shall be by manual
means in accordance with 9.6.2 and by means of any required
sprinkler system waterflow alarms, detection devices, or detection
systems. 18.3.4.2, 19.3.4.2, 9.6.2.1

K61

Required automatic sprinkler systems shall have valves
supervised so that at least a local alarm will sound when the
valves are closed. 9.7.2.1, NFPA 72

K62

Automatic sprinkler systems are continuously maintained
in reliable operating condition and are inspected and tested
periodically. 18.7.6, 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

K63

Required automatic sprinkler systems have an adequate and
reliable water supply which provides continuous and automatic
pressure. 9.7.1.1, NFPA 13

K64

Portable fire extinguishers shall be provided in all health care
occupancies in accordance with 9.7.4.1, NFPA 10.
18.3.5.6, 19.3.5.6

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Page 19

Name of Facility

2000 CODE

ID
PREFIX

MET NOT
MET

N/A

REMARKS

SMOKING REGULATIONS
K66

Smoking regulations shall be adopted and shall include not less
than the following provisions: 18.7.4, 19.7.4
■ (1) Smoking shall be prohibited in any room, ward, or
compartment where flammable liquids, combustible gases,
or oxygen is used or stored in any other hazardous location,
and such area shall be posted with signs that read NO
SMOKING or shall be posted with the international symbol
for no smoking.
■ (2) Smoking by patients classified as not responsible shall be
prohibited, except when under direct supervision.
■ (3) Ashtrays of noncombustible material and safe design shall
be provided in all areas where smoking is permitted.
■ (4) Metal containers with self-closing cover devices into which
ashtrays can be emptied shall be readily available to all
areas where smoking is permitted.
BUILDING SERVICE EQUIPMENT

K67

Heating, ventilating, and air conditioning shall comply with 9.2
and shall be installed in accordance with the manufacturer’s
specifications.
18.5.2.1, 19.5.2.1, 9.2, NFPA 90A, 18.5.2.2, 19.5.2.2

K68

Combustion and ventilation air for boiler, incinerator and heater
rooms is taken from and discharged to the outside air.
18.5.2.2, 19.5.2.2.

K69

Cooking facilities shall be protected in accordance with 9.2.3.
18.3.2.6, 19.3.2.6, NFPA 96

K70

Portable space heating devices shall be prohibited in all health
care occupancies. Except it shall be permitted to be used in
non-sleeping staff and employee areas where the heating
elements of such devices do not exceed 212oF (100oC).
18.7.8, 19.7.8

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Page 20

Name of Facility
ID
PREFIX

K71

2000 CODE
MET NOT
MET

N/A

REMARKS

Rubbish Chutes, Incinerators and Laundry Chutes.
18.5.4, 19.5.4, 9.5, 8.4, NFPA 82
■ (1) Any existing linen and trash chute, including pneumatic
rubbish and linen systems, that opens directly onto any
corridor shall be sealed by fire resistive construction to
prevent further use or shall be provided with a fire door
assembly having a fire protection rating of 1 hour. All new
chutes shall comply with 9.5.
■ (2) Any rubbish chute or linen chute, including pneumatic
rubbish and linen systems, shall be provided with automatic
extinguishing protection in accordance with 9.7.
■ (3) Any trash chute shall discharge into a trash collection room
used for no other purpose and protected in accordance
with 8.4.
■ (4) Existing flue-fed incinerators shall be sealed by fire
resistive construction to prevent further use.

K160

2000 EXISTING
All existing elevators, having a travel distance of 25 ft or more
above or below the level that best serves the needs of
emergency personnel for fire fighting purposes, conform with
Firefighter’s Service Requirements of ASME/ ANSI A17.3,
Safety Code for Existing Elevators and Escalators.
19.5.3, 9.4.3.2
ANSI A17.1 states 25 ft or more above or below the designated
level and defines “designated level” as the main floor or other
floor level that best serves the needs of emergency personnel for
fire fighting purposes or rescue purposes identified by the
building code or fire authority. Depending on floor slab thickness
and heights this would generally apply to a three-story building,
and almost certainly to a four-story building.
Includes firefighters service phase I key recall and smoke
detector automatic recall, firefighters service phase II
emergency in-car key operation, machine room smoke detectors,
and elevator lobby smoke detectors. 19.5.3, 9.4.3.2

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Page 21

Name of Facility

2000 CODE

ID
PREFIX

K161

MET NOT
MET

N/A

REMARKS

2000 EXISTING
All existing escalators, dumbwaiters, and moving walks conform
to the requirements of ASME/ ANSI A17.3, Safety Code for
Existing Elevators and Escalators. 19.5.3, 9.4.2.2
Includes escalator emergency stop buttons and automatic skirt
obstruction stop. For power dumbwaiters includes hoistway door
locking to keep doors closed except for floor where car is being
loaded or unloaded.
2000 NEW
All elevators, escalators, and conveyors comply with
ASME/ ANSI A17.1, Safety Code for Elevators and Escalators
(Includes car emergency signaling, firefighters service phase I
key and smoke detector automatic recall, firefighters service
phase II emergency in-car operation, machine room smoke
detectors, elevator lobby smoke detectors). 18.5.3, 9.4
FURNISHINGS AND DECORATIONS

K72

Means of egress shall be continuously maintained free of all
obstructions or impediments to full instant use in the case of fire
or other emergency. No furnishings, decorations, or other objects
shall obstruct exits, access thereto, egress there from, or visibility
thereof shall be in accordance with 7.1.10

K73

No furnishings or decorations of highly flammable character shall
be used. 18.7.5.2, 18.7.5.3, 18.7.5.4, 19.7.5.2, 19.7.5.3, 19.7.5.4

K74

Draperies, curtains, including cubicle curtains, and other loosely
hanging fabrics and films serving as furnishings or decorations in
health care occupancies shall be in accordance with provisions
of 10.3.1 and NFPA 13 Standard for the Installation of Sprinkler
Systems. Except shower curtains shall be in accordance with
NFPA 701.
■ Newly introduced upholstered furniture shall meet the
criteria specified when tested in accordance with the methods
cited in 10.3.2 (2) and 10.3.1. 18.3.5.3 and NFPA 13
■ Newly introduced mattresses shall meet the criteria specified
when tested in accordance with the method cited in 10.3.2 (3)
and 10.3.4. 18.7.5.3, 19.7.5.3
Newly introduced upholstered furniture and mattresses means
purchased since March, 2003.

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Name of Facility

2000 CODE

ID
PREFIX

K75

MET NOT
MET

N/A

REMARKS

Soiled linen or trash collection receptacles shall not exceed 32
gal (121 L) in capacity. The average density of container capacity
in a room or space shall not exceed .5 gal/ft2 (20.4 L/m2). A
capacity of 32 gal (121 L) shall not be exceeded within any 64-ft2
(5.9-m2) area. Mobile soiled linen or trash collection receptacles
with capacities greater than 32 gal (121 L) shall be located in a
room protected as a hazardous area when not attended.
18.7.5.5, 19.7.5.5
LABORATORIES

K31

Laboratories employing quantities of flammable, combustible, or
hazardous materials that are considered a severe hazard shall be
protected in accordance with NFPA 99. (Laboratories that are not
considered to be severe hazard shall meet the provision of K29.)
Laboratories in Health Care occupancies and medical and dental
offices shall be in accordance with NFPA 99, Standard for Health
Care Facilities 10.5.1.

K136

Procedures for laboratory emergencies shall be developed.
Such procedures shall include alarm actuation, evacuation,
and equipment shutdown procedures, and provisions for control
of emergencies that could occur in the laboratory, including
specific detailed plans for control operations by an emergency
control group within the organization or a public fire department
in accordance with NFPA 99, 10.2.1.3.1, 18.3.2.2., 19.3.2.1

K131

Emergency procedures shall be established for controlling
chemical spills in accordance with NFPA 99. 10.2.1.3.2

K132

Continuing safety education and supervision shall be provided,
incidents shall be reviewed monthly, and procedures reviewed
annually shall be in accordance with NFPA 99. 10.2.1.4.2

K133

Fume hoods shall be in accordance with NFPA 99. 5.4.3, 5.6.2

K134

Emergency Shower:
Where the eyes or body of any person can be exposed to
injurious corrosive materials, suitable fixed facilities for quick
drenching or flushing of the eyes and body shall be provided
within the work area for immediate emergency use. Fixed eye
baths designed and installed to avoid injurious water pressure
shall be in accordance with NFPA 99, 10.6.

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Page 23

Name of Facility
ID
PREFIX

K135

2000 CODE
MET NOT
MET

N/A

REMARKS

Flammable and combustible liquids shall be used from and
stored in approved containers in accordance with NFPA 30,
Flammable and Combustible Liquids Code, and NFPA 45,
Standard on Fire Protection for Laboratories Using Chemicals.
Storage cabinets for flammable and combustible liquids shall be
constructed in accordance with NFPA 30, Flammable and
Combustible liquids Code NFPA 99, 4.3, 10.7.2.1.
MEDICAL GASES AND ANESTHETIZING AREAS

K76

Medical gas storage and administration areas shall be protected
in accordance with NFPA 99, Standard for Health Care Facilities.
(a) Oxygen storage locations of greater than 3,000 cu.ft. are
enclosed by a one-hour separation.
(b) Locations for supply systems of greater than 3,000 cu.ft. are
vented to the outside. NFPA 99, 4.3.1.1.2, 18.3.2.4, 19.3.2.4

K77

Piped in medical gas systems comply with NFPA 99, Chapter 4.

K78

Anesthetizing locations shall be protected in accordance with
NFPA 99, Standard for Health Care Facilities.
(a) Shutoff valves are located outside each anesthetizing
location and arranged so that shutting off one room or
location will not affect others.
(b) Relative humidity is maintained equal to or great
than 35%
NFPA 99 4.3.1.2.3(n) and 5.4.1.1, 18.3.2.3, 19.3.2.3

K140

(a) Master alarm panels are in two separate locations and
have audible and visible signals.
(b) There are high/low alarms for +/- 20% operating pressure.
This section shall be in accordance with NFPA 99, 4.3.1.2.2
(c) Where a level 2 gas system is used, one alarm panel that
complies with 4.3.1.2.2(b) 3 a, b, c and d and with 4.3.1.2.2(c)
2 and 5 shall be permitted. (4.4.1 exception No. 4).

K141

Non-smoking and no smoking signs in areas where oxygen is
used or stored shall be in accordance with 18.3.2.4, 19.3.2.4,
NFPA 99, 8.6.4.2

K142

All occupancies containing hyperbaric facilities shall comply with
NFPA 99, Standard for Health Care Facilities, Chapter 19.

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Page 24

Name of Facility

2000 CODE

ID
PREFIX

K143

MET NOT
MET

N/A

REMARKS

Transferring of oxygen shall be:
(a) separated from any portion of a facility wherein patients
are housed, examined, or treated by a separation of a fire
barrier of 1-hour fire-resistive construction; and
(b) the area that is mechanically ventilated, sprinklered, and
has ceramic or concrete flooring; and
(c) in an area that is posted with signs indicating that
transferring is occurring, and that smoking in the
immediate area is not permitted in accordance with
NFPA 99 and Compressed Gas Association. 8.6.2.5.2
ELECTRICAL

K106

The hospital and all nursing homes and hospices with life support
equipment has a Type I Essential Electrical System powered by
a generator with a transfer switch and separate power supply.
The EES is in accordance with NFPA 99, 3.4.2.2, 3.4.2.1.4

K144

Generators inspected weekly and exercised under load for
30 minutes per month and shall be in accordance with NFPA 99,
3.4.4.1, NFPA 110, 8.4.2

K145

The Type I EES is divided into the critical branch, life safety
branch and the emergency system and shall be in accordance
with NFPA 99, 3.4.2.2.2

K146

The nursing home/hospice with no life support equipment shall
have an alternate source of power separate and independent
from the normal source that will be effective for minimum of 11/2
hour after loss of the normal source NFPA 99, 3.6.

K147

Electrical wiring and equipment shall be in accordance with
NFPA 70, National Electrical Code. 9.1.2

K130

Miscellaneous
List in the REMARKS sections, any items that are not listed
previously, but are deficient. This information, along with the
applicable Life Safety Code or NFPA standard citation, should
be included on Form CMS-2567.

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Page 25

Name of Facility

2000 CODE
PART IV RECOMMENDATION FOR WAIVER OF SPECIFIC LIFE SAFETY CODE PROVISIONS
For each item of the Life Safety code recommended for waiver, list the survey report form item
number and state the reason for the conclusion that: (a) the specific provisions of the code, if rigidly
applied, would result in unreasonable hardship on the facility, and (b) the waiver of such unmet
provisions will not adversely affect the health and safety of the patients. If additional space is
required, attach additional sheet(s).

PROVISION NUMBER(S)

JUSTIFICATION

K84

Surveyor (Signature)

Title

Office

Date

Fire Authority Official (Signature)

Title

Office

Date

Form CMS-2786R (xx/xx) Previous Versions Obsolete

Page 26

DATE OF PLAN
APPROVAL

2786U
ICF/MR Form
2786V, W, X
2000 EXISTING
2000 NEW
2786V, W, X

16
17

SELECT NUMBER OF FORM USED FROM ABOVE

2000 NEW

2786U

14
15

(COMP. WITH
ALL PROVISIONS)

A1.

(ACCEPTABLE POC)

A2.

Form CMS-2786R (xx/xx) Previous Versions Obsolete

* MANDATORY

B.

A.

7 PROMPT
8 SLOW
9 IMPRACTICAL

K5:

BUILDING
WING
FLOOR
APARTMENT UNIT

(FSES)

(All required areas are sprinklered) (Not all required areas are sprinklered)

PARTIALLY SPRINKLERED

B.

A4.

e.g. 2.5

ENTER E – SCORE HERE

K8:

FULLY SPRINKLERED

K0180

4 PROMPT
5 SLOW
6 IMPRACTICAL

1 PROMPT
2 SLOW
3 IMPRACTICAL

(16 BEDS OR LESS)

APARTMENT HOUSE

K8:

LARGE

K8:

SMALL

(WAIVERS)

A3.

____________

A
B
C
D

* K4

SURVEY DATE

NONE

Page 27

(No sprinkler system)

C.

(PERFORMANCE
BASED DESIGN)

A5.

COMPLETE IF ICF/MR IS SURVEYED UNDER CHAPTER 21

FACILITY MEETS LSC BASED ON (Check all that apply)

K56:

FACILITY DOES NOT MEET LSC

*K9:

K29:

(Check if K29 or K56 are marked as not applicable
in the 2786 M, R, T, U, V, W, X and Y.)

* K7

NUMBER OF THIS BUILDING

ASC Form
2000 EXISTING

12
13

MULTIPLE CONSTRUCTION

TOTAL NUMBER OF BUILDINGS ____________

K3

FACILITY NAME

Health Care Form
2786R
2000 EXISTING
2786R
2000 NEW

LSC FORM INDICATOR

K6

K1

PROVIDER NUMBER

FIRE SAFETY SURVEY REPORT
CRUCIAL DATA EXTRACT
(TO BE USED WITH CMS-2786 FORMS)