CMS-2786 M Fire Safety Survey Report

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

Form Approved
OMB No. 0938-0242

FIRE SAFETY SURVEY — 2000 LIFE SAFETY CODE

F-1

Worksheet for Rating Residents

SIDE 1

Complete one Worksheet for each resident.
Read Instruction Manual before filling out this form.
Base ratings on commonly observed examples of poor performance.

Resident’s Name

Rater

Facility

Date

Write any explanatory remarks you may wish to make here:

Surveyor (Signature)

Title

Date

Title

Date

Surveyor ID
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.
Form CMS-2786M (03/04) Previous Versions Obsolete

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Form Approved
OMB No. 0938-0242

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

F-1

COMPLETE OTHER SIDE FIRST
Worksheet for Rating Residents

SIDE 2

Read Instruction Manual before filling out this form.
Base ratings on commonly observed examples of poor performance.

F-1A Rating the Resident on the Risk Factors
Rating the resident on each of the factors below by checking the one circle in each risk factor that best describes the resident. For the first six
factors, write the scores for the circles you checked in the appropriate score boxes in the far right column. For "response to fire drills," write the
three checked scores in the large circles. Write the sum of the 3 scores in the large box on the right.

SCORE
BOXES
I. Risk of
Resistance

(Check only one)
II. Impaired
Mobility

(Check only one)

Minimal
Risk

score = 0
SelfStarting

IV. Need for
Extra Help

(Check only one)
V. Response to
Instructions

(Check only one)
VI. Waking
Response to
Alarm
(Check only one)
VII. Response
to Fire Drills

(Without
Guidance or
Advice from
Staff)

Slow

score = 3

Needs Limited
Assistance
from 2 Staff

score = 1
Response
Probable

score = 20

score = 20
Needs Full
Assistance
from 2 Staff
score = 40
Requires Considerable Attention/May
Not Respond

score = 3

score = 10

Response
Not Probable

score = 0
Initiates and
Completes
Evacuation
Promptly

score = 6

score = 30
Requires
Supervision

Needs Full
Assistance or
Very Slow

Totally
Impaired

score = 6

score = 0
Follows
Instructions

score = 20
Needs Limited
Assistance

Partially
Impaired

score = 0
Needs at Most
One Staff

Risk of Strong
Resistance

score = 6

score = 0

No Significant
III. Impaired
Consciousness Risk

(Check only one)

Risk of Mild
Resistance

score = 6
Yes

No

score = 0
Chooses and
Completes
Back-up
Strategy

Yes

Stays at
Designated
Location

Yes

score = 8
No

score = 0

+
score = 4

No

score = 0

+
score = 6

F-1B Finding the ResIdent’s Overall Need
For AssIstance
Compare the numbers in the 7 score boxes you have filled in.
Take the one highest score from the score boxes and write it in this box:
Form CMS-2786M (03/04) Previous Versions Obsolete

SUM OF
THESE
THREE
ITEMS

EVACUATION
ASSISTANCE
SCORE
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FIRE SAFETY SURVEY REPORT
CRUCIAL DATA EXTRACT
(TO BE USED WITH CMS-2786 FORMS)
PROVIDER NUMBER

FACILITY NAME

SURVEY DATE

K1

K6

* K4

K3

DATE OF PLAN
APPROVAL

MULTIPLE CONSTRUCTION

TOTAL NUMBER OF BUILDINGS ____________
NUMBER OF THIS BUILDING

LSC FORM INDICATOR

____________

12
13

14
15

ASC Form
2000 EXISTING
2000 NEW

SMALL

(16 BEDS OR LESS)

K8:

1 PROMPT
2 SLOW
3 IMPRACTICAL

LARGE

K8:

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

16
17

SELECT NUMBER OF FORM USED FROM ABOVE

*K9:

7 PROMPT
8 SLOW
9 IMPRACTICAL

ENTER E – SCORE HERE

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

4 PROMPT
5 SLOW
6 IMPRACTICAL

APARTMENT HOUSE

K8:
* K7

BUILDING
WING
FLOOR
APARTMENT UNIT

COMPLETE IF ICF/MR IS SURVEYED UNDER CHAPTER 21

Health Care Form
2786R
2000 EXISTING
2786R
2000 NEW

2786U
2786U

A
B
C
D

K5:

K56:

e.g. 2.5

FACILITY MEETS LSC BASED ON (Check all that apply)
A1.
(COMP. WITH
ALL PROVISIONS)

A2.

A3.

(ACCEPTABLE POC)

FACILITY DOES NOT MEET LSC
B.

A4.

(WAIVERS)

A5.
(FSES)

(PERFORMANCE
BASED DESIGN)

K0180

A.
FULLY SPRINKLERED

B.
PARTIALLY SPRINKLERED

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

C.
NONE
(No sprinkler system)

* MANDATORY

Form CMS-2786M (03/04) Previous Versions Obsolete

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