CMS-2786S Fire & Safety Survey Report

2000 CODE

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

FIRE SAFETY SURVEY REPORT SHORT FORM
Medicare – Medicaid

Form Approved
OMB No. 0938-0242

1. (A) PROVIDER NUMBER

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

K1

K2

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.

(All required areas are sprinklered)

A. BUILDING ________________
B. WING

________________

C. FLOOR

________________

K3

3. SURVEY FOR

■

MEDICARE

B.

Sprinklered
■ Partially
(Not all required areas are sprinklered)

C.

■ None (No sprinkler system)

K0180

SHORT FORM

4. DATE OF SURVEY

■

■ Fully Sprinklered

CHECK HERE

MEDICAID
K4

SURVEY UNDER

■

5.

■ 2000 EXISTING

■ 2000 NEW

K5

5. SURVEY FOR CERTIFICATION OF
1.

■

HOSPITAL

2.

■

SKILLED/NURSING FACILITY

K8

IF “2” OR “3” ABOVE IS MARKED, CHECK APPROPRIATE ITEM(S) BELOW
1.

■ ENTIRE FACILITY

2.

3.

■ DISTINCT PART OF (SPECIFY)_____________________________

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

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

b. NUMBER OF HOSPITAL BEDS
CERTIFIED FOR MEDICARE

c. NUMBER OF SKILLED BEDS
CERTIFIED FOR MEDICARE

d. NUMBER OF SKILLED BEDS
CERTIFIED FOR MEDICAID
K9: FOR STATE AGENCY USE ONLY
A.
The facility MEETS based upon:

I HAVE CONDUCTED A FIRE SAFETY SCREENING USING THE SHORT FORM:

■

■ The facility meets all of the items on the form.
B. ■ The facility does not meet all of the items on the form.
C. ■ A complete fire safety survey is recommended.
A.

■ Compliance with all provisions
■ Acceptance of a Plan of Correction
3. ■ Recommended waivers.

1.
2.
B.

K9

SURVEYOR (Signature)

e. NUMBER OF ICF BEDS
CERTIFIED FOR MEDICAID

■ The facility DOES NOT MEET THE STANDARD.

TITLE

OFFICE

DATE

TITLE

OFFICE

DATE

8. SURVEYOR I.D. NO
K10

REVIEW 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.
Form CMS-2786S (xx/xx)

Page 1

Name of Facility

2000 CODE

ID
PREFIX

MET

NOT
MET

N/A

REMARKS

CORRIDOR WALLS AND DOORS
K18

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.
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.

If all vertical openings are properly enclosed with construction
providing at least a two hour fire resistance rating, also check
this box. ■
Form CMS-2786S (xx/xx)

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Name of Facility
ID
PREFIX

2000 CODE
MET

NOT
MET

N/A

REMARKS

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.
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

K28

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

Form CMS-2786S (xx/xx)

Page 3

Name of Facility

2000 CODE

ID
PREFIX

MET

NO
MET

N/A

REMARKS

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
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.

Form CMS-2786S (xx/xx)

Page 4

Name of Facility

2000 CODE

ID
PREFIX

MET

NO
MET

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

Automatic Sprinkler

Separation

N/A

18.2.6, 19.2.6
K211

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 482.41, 483.70, 483.623

Form CMS-2786S (xx/xx)

Page 5

Name of Facility

2000 CODE

ID
PREFIX

K211

MET

NO
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 482.41, 483.70, 483.623
EXISTS AND EGRESS

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

Form CMS-2786S (xx/xx)

Page 6

Name of Facility

2000 CODE

ID
PREFIX

K43

MET

NO
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 health
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
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

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

K105

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).

Form CMS-2786S (xx/xx)

Page 7

Name of Facility

2000 CODE

ID
PREFIX

MET

NO
MET

N/A

REMARKS

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
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 NFPA 72, 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

Form CMS-2786S (xx/xx)

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Name of Facility
ID
PREFIX

2000 CODE
MET

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 fires 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

K53

2000 EXISTING (INDICATE N/A FOR HOSPITALS 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

NO
MET

N/A

REMARKS

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

Form CMS-2786S (xx/xx)

Page 9

Name of Facility

2000 CODE

ID
PREFIX

K109

MET

NO
MET

N/A

REMARKS

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
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
When required by construction type, 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.
A. Date sprinkler system last checked and necessary
maintenance provided. _______________________________
B. Show who provided the service. _______________________

Form CMS-2786S (xx/xx)

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Name of Facility

2000 CODE

ID
PREFIX

MET

K154

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

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

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

NO
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.

Form CMS-2786S (xx/xx)

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Name of Facility

2000 CODE

ID
PREFIX

MET

NO
MET

N/A

REMARKS

BUILDING SERVICE EQUIPMENT
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
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

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
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.

Form CMS-2786S (xx/xx)

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Name of Facility
ID
PREFIX

2000 CODE
MET

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.

K135

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.

NO
MET

N/A

REMARKS

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

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

K143

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

Form CMS-2786S (xx/xx)

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Name of Facility

2000 CODE

ID
PREFIX

MET

NO
MET

N/A

REMARKS

ELECTRICAL
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.

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

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.

Form CMS-2786S (xx/xx)

Page 14

Form CMS-2786S (xx/xx)

* MANDATORY

B.

FACILITY DOES NOT MEET LSC:

(COMP. WITH ALL PROVISIONS)

A1.

A.

9 IMPRACTICAL

8 SLOW

K5:

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

NONE

Page 14

(No sprinkler system)

C.

A4.
(FSES)

BUILDING
WING
FLOOR
APARTMENT UNIT

PARTIALLY SPRINKLERED

B.

(WAIVERS)

A3.

e.g. 2.5

ENTER E – SCORE HERE

K8:

7 PROMPT

APARTMENT HOUSE

K8:

4 PROMPT
5 SLOW
6 IMPRACTICAL

1 PROMPT
2 SLOW
3 IMPRACTICAL

K8:

LARGE

(16 BEDS OR LESS)

SMALL

FULLY SPRINKLERED

K0180

A
B
C
D

* K4

SURVEY DATE

COMPLETE IF ICF/MR IS SURVEYED UNDER CHAPTER 21

____________

(ACCEPTABLE POC)

A2.

*K9: FACILITY MEETS LSC BASED ON: (Check all that apply)

K29:

(Check if not applicable)

K56:

SELECT NUMBER OF FORM USED FROM ABOVE

*K7

NEW

P-85

2786 A-67
EXISTING
A-67
NEW
B-73
EXISTING
B-73
NEW
F-81
EXISTING
F-81
NEW
C-SHORT
H-ASC
J, K, L
85-CHAPTER 21
(ICFs/MR ONLY)
EXISTING
P-85

NUMBER OF THIS BUILDING

TOTAL NUMBER OF BUILDINGS ____________

FACILITY NAME

10
11

1
2
3
4
5
6
7
8
9

LSC FORM INDICATOR

* K4 MULTIPLE
CONSTRUCTION

PROVIDER NUMBER

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