When CMS surveyors determine that a hospital has put patients in “immediate jeopardy,” the deficiency that triggers it is far more often a breakdown in patients’ rights than a clinical error, federal data shows.
That is the clearest pattern in a Becker’s analysis of 278,837 hospital deficiency citations recorded on CMS Form 2567 statements of deficiency from 2010 through mid-June 2026. Across this period, approximately 4,300 hospital survey events involved at least one citation written up as immediate jeopardy, and one condition of participation tops the list year after year: patient rights.
The analysis comes as CMS sharpens its scrutiny of how hospital accreditation surveys get conducted. On June 12, the agency finalized a rule tightening oversight of the nine accrediting organizations that survey more than 9,000 healthcare organizations a year, banning pre-arrival notifications and survey blackout dates, restricting pre-survey consulting and standardizing surveyor training to curb inconsistency.
Patient rights citations lead
Patient rights (tag A-0115), the condition of participation governing how hospitals treat the people in their care, is the single citation most frequently leading to an immediate jeopardy. Since 2010, 752 immediate jeopardy citations have been linked to this deficiency, more than twice the next category. Its sub-requirements pile on: care in a safe setting (A-0144) and freedom from abuse and harassment (A-0145) rank among the top 10.
Among the most commonly cited tags in recent years (2023-26), about 1 in 5 patient rights citations had a narrative that explicitly cited immediate jeopardy. This is double the rate of any other tag. By comparison, infection prevention citations crossed into immediate jeopardy about 12% of the time and nursing services about 10%.
The 10 hospital citations most often tied to immediate jeopardy, 2010-26:
1. A-0115 — Patient rights: 752
2. A-0385 — Nursing services: 347
3. A-0144 — Patient rights: care in a safe setting: 310
4. A-0043 — Governing body: 209
5. A-0747 — Infection prevention, control and antibiotic stewardship: 147
6. A-0749 — Infection control program: 110
7. A-0700 — Physical environment: 100
8. A-0145 — Patient rights: freedom from abuse and harassment: 93
9. A-0395 — RN supervision of nursing care: 92
10. A-0263 — QAPI (quality assessment and performance improvement): 91
Immediate jeopardy findings climbed for a decade
The frequency of immediate jeopardy findings rose steadily before easing over the last few years. Hospital survey events involving immediate jeopardy grew from 103 in 2010 to a peak of 436 in 2023, and the share of all hospital surveys that turned up an immediate jeopardy roughly doubled, from about 3% in 2010 to a high of 8.2% in 2023, before calming to 6.1% in 2024 and 5.5% in 2025.
Between Jan. 1 and June 12 of this year, 75 survey events at 70 hospitals had involved an immediate jeopardy citation, according to CMS data.
Patient rights immediate jeopardy citations tracked that arc, climbing from the mid-40s annually early in the decade to well over 100 in recent years. Comparing the first half of the period (2010-17) with the second (2018-26), patient rights, nursing services, governing body and infection prevention remained the consistent leaders, but freedom from abuse citations rose into the top tier in the later years.
Methodology
This analysis is based on hospital CMS Form 2567 statements of deficiency for 2010 through June 12, 2026, covering 278,837 citation records. The dataset does not include CMS scope-and-severity letters (J, K and L denote immediate jeopardy), so immediate jeopardy citations were identified by detecting “immediate jeopardy” language within each citation’s narrative text.
Surveyors state the finding explicitly in the 2567 narrative, but it is text-derived rather than drawn from the official scope-severity code, and counts should be read as close estimates. Trend figures count distinct survey events, as a single survey can generate multiple citations.
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