This is a CMS fire safety survey form (CMS-2786R) used by surveyors to document fire safety inspection results for healthcare and IDD residential facilities. It captures facility identification data, building construction details, Life Safety Code (LSC) form indicators, and evacuation capability ratings. Operators of ICF/IID facilities must be aware that specific LSC form variants (2786V, W, X) and evacuation classifications apply to their buildings.
View official sourceK400 Surveyor (Signature) Title Office Date Fire Authority Official (Signature) Title Office Date Form CMS-2786R (07/2018) Page 49 PART IV - FIRE SAFETY SURVEY REPORT CRUCIAL DATA EXTRACT (TO BE USED WITH CMS 2786 FORMS) Provider Number Facility Name Survey Date K1 *K4 K6 DATE OF PLAN APPROVAL K3 MULTIPLE CONSTRUCTION 󠇃 A. BUILDING TOTAL NUMBER OF BUILDINGS ______ B. WING C. FLOOR NUMBER OF THIS BUILDING _______ D. APARTMENT UNIT LSC FORM INDICATOR HEALTH CARE FORM 12 2786R 2012 EXISTING 13 2786R 2012 NEW AHCO FORM 14 2786U 2012 EXISTING 15 2786U 2012 NEW ICF/IID FORM 16 2786V, W, X 2012 EXISTING 17 2786V, W, X 2012 NEW *K7 󠇃SELECT NUMBER OF FORM USED FROM ABOVE COMPLETE IF ICF/IID IS SURVEYED UNDER CHAPTER 33, EXISTING SMALL (16 BEDS OR LESS) K8 󠇃 1. PROMPT 2. SLOW 3. IMPRACTICAL LARGE K8 󠇃 4. PROMPT 5. SLOW 6. IMPRACTICAL APARTMENT HOUSE K8 󠇃 7. PROMPT 8. SLOW 9. IMPRACTICAL (Check if K321 or K351 are marked as not applicable in the 2786 M, R, T, U, V, W, X, and Y.)