By Richard T. Moore
This commentary was posted on the “Members’ Forum” of the American Geriatric Society on January 25, 2026.
Not long ago, I watched a CNA gently turn an older resident to adjust her pillows. As her body shifted, a deep pressure ulcer came into view – the kind of wound that never appears without warning, never emerges without a cascade of failures. The resident saw the CNA’s concern and whispered, “I didn’t mean to be a bother.”
A resident apologizing to the caregiver who discovered the injury – apologizing for a wound she did not cause – is what long-term care has taught too many older adults. It has conditioned them to absorb the blame for systemic neglect. And that wound on her skin is more than a clinical problem. It is a map of the forces that are tearing long term care apart. Because the same three forces that create a pressure ulcer – pressure, friction, and shear – are the forces destroying the system meant to protect her.
Pressure: The force that cuts off the lifeblood of care – Every geriatrician knows what happens when pressure is not relieved. Blood flow stops. Tissue starves. Damage begins long before the wound becomes visible. The long term care system is experiencing its own form of unrelieved pressure: the constant demand for higher profit margins. Private equity structures, related‑party transactions, and reimbursement‑driven business models squeeze every possible dollar out of care.
And layered on top of this is another manufactured pressure – the industry’s relentless claim of “Medicaid underpayment,” built on pseudoscientific analyses of self‑reported, unaudited, and often inaccurate cost reports. Federal oversight bodies have repeatedly warned that these reports cannot be treated as reliable evidence of financial distress. The Government Accountability Office has documented significant inaccuracies in nursing home cost reporting, including inconsistent treatment of related‑party transactions and wide variation in how facilities classify administrative versus care‑related expenses. The HHS Office of Inspector General has similarly found that related‑party arrangements allow owners to inflate reported costs by paying themselves above‑market rates for management, real estate, and staffing services – all while presenting these inflated payments as “care costs” in Medicaid filings. State audits in New York, Massachusetts, and Pennsylvania echo the same pattern: facilities overstating costs, underreporting profits, or shifting revenue to related companies while claiming financial hardship.
Despite these red flags, the industry continues to present this unverified data as objective proof of underfunding – even though no audit trail exists to show that additional Medicaid dollars, when granted, flow to resident care rather than corporate profit streams. GAO has explicitly warned that without transparency and verification; policymakers cannot assume that higher reimbursement rates will improve staffing or quality.This pressure cuts off the lifeblood of the system – staffing hours, clinical oversight, time for repositioning, hydration, toileting, and human connection. Just as tissue deprived of oxygen begins to die, a care environment deprived of resources begins to fail. The wound on that resident’s skin was not an accident. It was the visible surface of a system under sustained, unrelieved pressure.
Friction: The grinding erosion of the workforce – But pressure alone doesn’t create a bedsore. Friction weakens the skin’s outer layer, making deeper injury inevitable. In long term care, friction is the slow, grinding erosion of the workforce – the very people who prevent harm. CNAs rushing through care because they have too many residents. Nurses juggling impossible caseloads. Turnover so constant that residents meet more new hires than familiar faces. This friction wears down the system’s protective layer. It thins the margin of safety until even routine tasks – turning, toileting, observing, comforting – become vulnerable to failure. When the workforce is worn down, the system’s defenses are gone. And the deeper damage begins.
Shear: The tearing apart of safety and dignity beneath the surface – The most devastating force in pressure ulcer formation is shear – the hidden tearing of tissue beneath the surface when the skin stays in place but the underlying bone shifts. The injury begins out of sight, long before the skin breaks open. Long-term care is experiencing its own form of shear: the widening gap between what residents need and what the system can provide. It is the tearing apart of safety and dignity under the strain of inadequate staffing, insufficient oversight, and financial incentives that reward efficiency over humanity. Shear is the resident who waits too long for help repositioning. Shear is the infection that goes unnoticed because no one had time to look. Shear is the fall that happens because the call light went unanswered. Shear is the quiet suffering that accumulates in the spaces where care should have been. By the time the wound appears – the hospitalization, the injury, the death – the underlying damage has already been done.
A pressure ulcer is never just a pressure ulcer. Clinicians know this. A pressure ulcer is a sentinel event – a sign that multiple systems have failed simultaneously. The same is true of long-term care. The wounds we see are not isolated incidents. They are the visible surface of deeper structural injuries caused by pressure, friction, and shear acting relentlessly on a fragile system. The resident who apologized for her own bedsore was not apologizing for a personal failure. She apologized for ours.
The American Geriatrics Society is well-positioned to name the wound – and demand its treatment. If any group understands the mechanics of harm, it is the AGS. We know how pressure ulcers form. We know how they progress. And we know they are preventable with the right support. The same is true of the long-term care crisis. This is the moment for AGS to say so with clinical precision and moral clarity:
- Relieve the pressure by aligning financial incentives with resident outcomes – not corporate extraction.
- Reduce the friction by establishing and enforcing staffing standards that reflect real acuity.
- Prevent the shear by strengthening oversight, transparency, and accountability.
Pressure ulcers heal only when all three forces are addressed. Long term care will heal only when the same principle is applied. The resident who whispered, “I didn’t mean to be a bother,” deserved a system that protected her before the wound appeared. Every older adult does. And AGS is uniquely positioned to say – with the authority of science and the urgency of conscience – that the wound is not theirs to bear. It is ours to heal.
The writer is a member of AGS and serves as Vice Chair of the Leadership Council for the National Consumer Voice for Quality Long-Term Care. He is also a co-founder of Dignity Alliance Massachusetts which advocates for older adults, people with disabilities and caregivers.