Passages – Life and Times of Morris Nathanson

Published in RINews Today on October 7, 2023

Painter, Illustrator and Restaurant/Hospitality Designer Morris Nathanson’s artist studio is just a stone’s throw away from his childhood home on Japonica Street in Pawtucket, Rhode Island. Growing up poor during the depression in his Pleasant View neighborhood, settled by Armenian and Syrian immigrants who worked in the surrounding mills, he would see his home and surrounding properties demolished to make way for Interstate 95. This made him skeptical of the policy of Eminent Domain, as it left his family and neighborhood languishing for years in expected dread of demolition, years before it was to occur, destroying the spirit of his neighborhood. It was this singular policy that encouraged his work in historic preservation.

Morris, raised in a Jewish household, was a lifelong adult member of Temple Beth El on Providence’s East Side.  He practiced his faith throughout his life including the orthodox values taught to him by his mother. 

Morris, a spitting image of Mark Twain, or maybe even Albert Einstein, because of his distinctive head of hair, always wore colorful bow ties, considered by many to be his trademark look. He was a man who made a definitive impact on the international art and design scene. In the City of Pawtucket, he was the force that initiated the City’s art scene by bringing the strategy of adaptive reuse of underutilized and vacant mills to city officials, a concept he learned from his years of working in New York City as a restaurant designer and watching the development and transformation of the industrial mill buildings in SOHO.

My friend, Morris, passed away peacefully at the ripe old age of 95 in September, one year ago.

Over two decades, this writer would visit Morris on Saturday afternoons sitting in his living room drinking cups of freshly brewed coffee. The cozy room is surrounded by large bookcases jam packed with literary classics, architectural, art and design books, and walls filled with artwork he created throughout the years, and of course the piles of newspapers, specifically the New York TimesBoston Globe and Providence Journal, that he read daily.  We would talk about Pawtucket, world events, and he would reminiscence about his amazing life’s journey from his childhood in Pawtucket, to the international world he lived in later in his life.

The War Years

Morris was motivated to enlist in the military service because of the Nazi’s policy of exterminating all Jews. His family was aware that they lost many of their relatives in Europe as they were transported to the concentration camps where they perished.  

Walking into the Pawtucket post office on Montgomery Street, registering for the draft at age 17, with the required parental approval to enlist in the Navy, he, like many young boys, left Pawtucket East to fight in World War II.

This memory never faded from his mind.

After his basic training at Sampson Naval Base in upstate New York, half of his class of Navy recruits were assigned to the U.S.S. Catamount (LSD 17) and the other half were sent to the U.S.S. Indianapolis. The U.S.S. Indianapolis was a Portland-class heavy cruiser which was charged with a top-secret mission – to deliver the uranium and other components for “Little Boy,” the first nuclear weapon to be used in combat, to Tinian Naval Base.  The bomb would be dropped on Hiroshima the following week.  After the ship’s departure to the Philippines for training duty, it was sunk by a Japanese submarine. Sinking in just 12 minutes.  Out of the 1,195 crewmen onboard, only 316 survived.  The survivors faced injuries, dehydration, and shark attacks. It was the luck of the draw for Morris to be assigned to serve on U.S.S. Catamount, and not the U.S.S. Indianapolis.

Morris remembered the U.S.S. Catamount among hundreds of naval ships in Tokyo Bay, carrying special equipment to be used during the occupation of Japan. His ship would ultimately not have to participate in the all-out ground invasion of Japan because of the dropping of the atomic bombs on Hiroshima and Nagasaki.  His ship was one of 260 vessels of the Allied navies present in Tokyo Bay when Japanese officials on the U.S.S. Missouri signed the declaration of surrender on Sept. 2, 1945.

With Japan’s surrender, the members of Morris’ crew were sent on shore to rout out any Japanese soldiers hiding in caves.  A terrifying moment for Morris occurred in the caves, not from meeting enemy soldiers, but realizing he was lost and he couldn’t read the signage written in Japanese. Fortunately, fate smiled on Morris and brought him out to safety. 

On a light note, during his Naval service Morris was recognized by his crewmates for his artistic talent.  He was always selected to do any assignments involving illustrations.  His favorite project was designing Mother’s Day cards for his shipmates.

Fighting Antisemitism and Civil Rights for All

Experience aboard the U.S.S. Catamount gave this young medic his first awareness of systemic racism.  Witnessing first hand man’s biases and prejudices motivated him throughout seventy-five years of his long life to fight for the equal rights of all.  Morris’s civil rights activism solidified his belief that human rights are essential to life and recognized that they must be consistently fought for.  Which he did.

Morris participated in the Freedom Rides of 1961, Dr. Martin Luther King’s campaigns in Selma and Birmingham, Alabama, and the March on Washington for Jobs and Freedom.  For anyone not familiar with the dangers and complexities of these marches – these courageous civil rights activists were subjected to threats, beatings, mass arrests, bombings and even murder.  Our criminal justice system in the 60s more often than not, turned a blind eye to the plight of those protesting against these injustices.

When Morris was discharged in 1945, like so many servicemen, he took advantage of the GI Bill, enrolling at Curry College in downtown Boston.  During his second year, with his best friend, Donnie Shear, they began to seek out Colleges, “anywhere warm” he would say.  They ultimately transferred to University of Miami.

At the University of Miami, he earned a Bachelor of Arts (BA) in Theatre and Fine Arts.  He was a member of Alpha Epsilon Pi, a Jewish fraternity on campus.  He later went on to the New School for Social Research in New York City to study Theatre.  At that time, he wanted to become a playwright and director for the New York stage but fate would bring him back to Rhode Island with a call from his mother asking him to return to help her provide for his younger siblings.

Finding a Niche in the Design Sector

Ultimately, the young college graduate took his first job as a social worker in Providence.  Morris worked for two years in the Charles Street neighborhood assisting struggling Italian families and although his supervisor offered to send him to graduate school in Boston to get a Bachelor of Social Work degree, he instead decided to follow his dreams and passion (suggested by his high school teachers) to become an artist.

Rhode Island would be pivotal to Morris by guiding him into his new profession.  His first design job, sort of like a one degree of separation, began when his brother Abe decided not to accept a job offered by the Providence-based Paramount Restaurant Supply Co.  When Morris heard this news, he went and applied for the job the next day and got it. This job officially propelled him into the restaurant design sector, working with the best, David Friedman, owner of Paramount Restaurant Supply Co.

Friedman had one of the largest design shops on the East Coast. The company designed case goods for numerous department stores in New York City, which had luncheonettes and restaurants.  Interesting enough, Morris’ first designs were drawn on paper napkins in front of his new clients.  However, that was very short lived as Morris immediately undertook developing a serious design department.

At age 24, Morris, head of the design team at Paramount, developed and designed the first franchise in American history, Dunkin Donuts. While working with Friedman he also designed restaurants in the pavilions of the 1964 World’s Fair in Flushing Meadows, New York.

When Morris left Paramount Restaurant Supply Co, he retained his relationship with Friedman which became a lifelong friendship. His artistic flair and design talents were brought out in his new company, Morris Nathanson Design, ultimately attracting clients throughout  Rhode Island, the U.S., and later, internationally.   

His most notable design projects locally include Hemenway’s, Ruth Chris Steak House, 22 Bowen, restaurants and bars for the Inn at Castle Hill, Capital Grill, Pizzeria Uno, Joe’s American Bar & Grill, Mills Tavern, Waterman Grill, Red Stripe and for those who still remember, the beloved Ming Garden and McGarry’s Restaurant in downtown Providence.  He also had clients in the legal, medical and retail sectors.

Well-known clients outside the Ocean State included Nathan’s Famous, B.B. King Blues Club, Carmine’s, Docks, Rue 57, Oceana, Virgil’s and Angelo and Maxie’s in Manhattan and the Hyde Park, New York-based Eveready Diner featured on the Food Network’s “Diners, Drive-in and Dives” television series.  Another accolade for the Eveready Diner is the 1995 visit of President Clinton and Russian President Boris Yeltsin to the diner for a meal during their summit held at the summer cottage of Franklin Delano Roosevelt, whose property is across the street from the diner. 

Morris was also instrumental in the ongoing development of Johnson & Wales University.  School leaders asked him to visit the renowned chef, Louis Szathmary, owner of The Bakery, in Chicago and a New York Times best-selling cookbook author, “The Chefs Secret Cookbook,” to review his extensive culinary collection which filled two Brownstones in Chicago.  Morris persuaded Szathmary to donate his entire collection of culinary memorabilia  to Johnson & Wales University and convinced the University to build a museum to house thousands of the historic artifacts that he so graciously donated.

An Early Advocate for Mill Adaptive Reuse

Morris did not forget or leave his old Pawtucket neighborhood.  With his offices in Providence, he would later return to his roots in the blue-collar community of Pawtucket and purchase the decaying Rhode Island Cardboard Manufacturing complex, now known as Blackstone Studios, just across the street from his former high school, East High, now Tolman High. 

Morris’s historic mill sits by Pawtucket’s Veterans Memorial Amphitheatre, an outdoor music venue he designed at Roosevelt and Exchange Street. Then the Exchange Street Bridge was later renamed the Morris Nathanson Bridge in his honor in 2010.

Over the years, Morris and his wife Phyllis renovated the former manufacturing mill building (ultimately located in Pawtucket’s 307-acre Arts and Entertainment District) to become the new headquarters of Morris Nathanson Design and also created artist studios and lofts, gathering a community of artists to live and work.  These artists and craft persons, residing in his mill, would become independent contractors of his design firm and would be hired to work with his company on many restaurant design projects. His clients loved this concept because it made it easy to manage all their design needs in one building. 

With the experiences learned in redeveloping their mill, Morris and his wife, Phyllis, took on developing the former Lebanon Knitting Mill and Vesta Underwear which sat on the banks of the Blackstone River.  The project is now known as Riverfront Lofts which houses 59 live-work condominiums for artists.  The success of this project was unrivaled in the state.

The Nathansons were leaders encouraging other artists to rehabilitate vacant buildings throughout Pawtucket and statewide. As an early advocate for mill adaptive reuse, Morris was in the forefront of developing Pawtucket as a highly visible and respected arts and entertainment center.  He led the efforts in the blue-collar community to change to zoning ordinances (locally and statewide) to assist developers to rehab vacant and underutilized mills to allow live-work spaces.

While residing in Rhode Island, Morris has lived his life on the international stage as a designer of award-winning restaurants, concert spaces, and hospitality venues. He was widely recognized as the father of modern restaurant and hospitality design.

A Prolific Fine Artist Who Made a Difference  

A lifetime member of the Providence Art Club, Morris was a highly respected and prolific fine artist, with numerous exhibitions in Providence and New York. The Pawtucket native’s paintings, prints, wood sculptures, and drawings reflect nearly a century of work, and trace his truly extraordinary and vibrant life through bold colors and iconography that pulled from personal history.

Mr. Nathanson was a founding board member of Trinity Repertory Company. One of Trinity Rep’s earliest set designers, he was also in charge of its relocation to the Emery’s Majestic Theater (now the Lederer Theater Center), which has been the theater’s home for over 50 years.   

Among his many activities in Rhode Island, Morris served as a member of the Providence Historic Commission and the Pawtucket Armory Association, he played a critical role in securing the historic armory from the State of Rhode Island and oversaw the design and build of the Sandra Feinstein Gamm Theatre and the creation the Jacqueline Walsh School for the Arts. He also offered his time and expertise to the City of Pawtucket’s Riverfront Commission, the Pawtucket 2020 Committee, the Pawtucket Foundation, and the Pawtucket Arts Collaborative.

Morris also found time to design and teach courses at the Rhode Island School of Design, and served as a design consultant to Providence Mayor Joseph Paolino Jr.  He also served as a commissioner under the direction of Antoinette Downing on the Providence Historic Commission.

Morris is the recipient of numerous personal awards and recognitions, including honorary doctorates from Johnson & Wales University and Rhode Island College. Morris has been inducted into the Pawtucket Hall of Fame, and been awarded the Pawtucket Foundation Heritage Award, the Arts and Business Council of Rhode Island’s Small Business Award, and the Pell Award from the Trinity Repertory Company for his life-time contribution to the arts. He was awarded the Paul Harris Award, Rotary’s highest honor by the Pawtucket Rotary Club.  

Morris has also been designated as a ‘Thought Leader’ by the American Society of Interior Designers, considered to be the best in the design community. 

Upon his retirement in 2008, Morris was asked by Boston University Culinary School to donate over 400 hand-drawn renderings of restaurants, hotel and resort projects, to become part of the new “Morris Nathanson Design Collection” at the Howard Gotlieb Archival Research Center.  Boston University recognized Morris’s lifelong work by calling him “the pioneer” of modern restaurant design. 

The Howard Gotlieb Archival Research Center also houses Martin Luther King’s letters, papers and archives, a fitting tribute to Morris’ years as a civil rights advocate.

With the international acclaim and recognition that Morris has received in his 95 years of living, Morris always would tell you where he comes from Pawtucket, a man who never forgot his roots.

Morris never consider himself retired; he just had a job as a full time artist.  

Morris is survived by his loving and devoted wife, Phyllis Van Orden Nathanson, and their son, John David Nathanson, and Josh Nathanson and Kim Nathanson Arsenault, from his marriage to Roxie Sgouros, along with four grandchildren, Emma, Sarah, Lily, Adrian and his sister Rachel Schuchman.

Morris’ legacy as an artist and designer lives on in his three children.  Josh and Kim are both involved in restaurant and hospitality design while John David is a following his love and passion creating animation films at DreamWorks in California.

Supporting Young Artists

Morris says that he knew that he would become an artist at the tender age of six years old, remembering that he would draw on the walls.  As he got older, he continued to sharpen his drawing skills. An elementary school teacher identified him as having artistic abilities and faculty at Tolman High School encouraged him to follow his passion for the arts.

To recognize the encouragement that Morris received throughout his schooling, Morris’s family has created “The Morris Nathanson Tribute Fund,” a scholarship supporting Rhode Island students aged K-12 to participate in Saturday youth classes at the Rhode Island School of Design (RISD) which he himself attended as a young boy.  The family hopes that the Rhode Island community will give generously to the “Morris Nathanson Tribute Fund” at RISD so that poor children with artistic talent may have the same opportunity to explore and cultivate these talents as he once did. 

Donations can be mailed to:  Morris Nathanson Scholarship Fund, Rhode Island School of Design, Office of Institutional Advancement, 20 Washington Place, Providence, RI 02903. 

By Herb Weiss and Phyllis Van Orden Nathanson

Herb Weiss, LRI -12, is a Pawtucket-based writer who has covered aging, health care and medical issues for over 43 years.  To purchase his books, Taking Charge: Collected Stories on Aging Boldly and a sequel, compiling weekly published articles, go to herbweiss.com.

Phyllis Van Orden Nathanson, wife of Morris Nathanson, continues her work as an arts advocate.

AARP report: States’ care for seniors “painfully inadquate”. Major gaps in RI

Published in RINewsToday on October 2, 2023

Last week, the Washington, DC-based AARP released its latest Long-Term Services and Supports (LTSS) Scorecard, calling care provided to seniors and persons with disabilities during the last three years after the COVID-19 pandemic “painfully inadequate.”  This nine-page report detailed state specific data, finds major gaps in providing care in every state, including Rhode Island, especially in these categories:  “Housing for Older Adults”, “Home Care Costs” and “Home Health Aide Supply”. 

The LTSS Scorecard, consisting of 50 indicators, focused on: affordability and access; choice of setting and provider; safety and quality; support for family caregivers; and community integration, using data from a variety of publicly available sources, such as the Centers for Medicare and Medicaid Services, American Community Survey, and Bureau of Labor Statistics.

Many benefits of accessing the data

According to AARP, this Scorecard can be a roadmap for improving the LTSS systems and the lives of those who rely on assistance.  Many others will benefit by reviewing this data, too. Federal, state, and local policy makers can identify priorities and ensure resources are allocated equitably. Aging advocates can glean public data and hold government officials accountable. Family caregivers can identify needed resources and become actively involved in policy discussions and advocacy. Seniors relying on long-term care programs and services can learn to inspire culture change and demand available tools. Finally, employers can improve workplace policies and practices to assist caregivers and healthcare groups so they can explore public-private partnerships and alliances. 

Like the findings reported in AARP’s LTSS Scorecard in 2020, Rhode Island ranked 12th in the country in 2023, but this year’s Scorecard reveals that the state has made some progress in improving care options for older Rhode Islanders, specifically the enrollment in the Program of All-Inclusive Care for the Elderly (PACE), as well as the availability of Adult Day Services.

“The pandemic reinforced the need to strengthen long-term care for countless loved ones across the country, including here in Rhode Island,” said AARP Rhode Island State Director Catherine Taylor in a Sept. 28th statement announcing the release of the 2023 LTSS Scorecard. 

“AARP’s Scorecard shows that there are many roads to meet the needs of all Rhode Islanders who deserve the very best care, including the 121,000 family caregivers in our state. The overwhelming majority — 87% — of Rhode Islanders age 45+ would prefer to receive care for themselves or loved ones at home with caregiver assistance. Yet, our low rankings in Housing for Older Adults (51st), Home Care Costs (43rd) and Home Health Aide Supply (41st) underscore how difficult it is for them to age the way they choose. It’s time to accelerate our efforts, for the sake of saving more lives,” she says.  

RI is dead last in housing

“In particular, Rhode Island’s dismal ranking for Housing for Older Adults – dead last – points to the urgent need to increase the supply of affordable, accessible housing. We can do that by passing legislation early in 2024 to strengthen homeowners’ ability to build an accessory dwelling unit (ADU) to allow them to age in place, support a family member, or house a caregiver,” Taylor said.

A national snapshot of the LTSS Scorecard’s 2023 Data

According to Scorecard, 12 states, including Rhode Island, have enacted paid family leave laws and 18 states have paid sick day laws, which can be used to assist caregivers. AARP’s latest Scorecard also reported that only 6 states provide a tax credit for family caregivers’ out-of-pocket expenses. Rhode Island does not provide a tax credit – nor is it among the 7 states that have statewide laws protecting caregivers from discrimination in the workplace that ensure they are not unfairly treated due to caregiving duties outside of work.

Meanwhile, it was reported that dozens of states experienced declines in the number of care choices that help support family caregivers. For instance, 16 states, including Rhode Island, had declines of 10% or more in access to home health aides since 2019. 

Regarding Home and Community-Based Services (HCBS), the LTSS Scorecard reported that 11 states, including Rhode Island, had state policies that improve presumptive eligibility for Medicaid HCBS at the time of data collection, making it possible for people to go home to receive care after being in the hospital – rather than having to be admitted to a nursing home while their eligibility for Medicaid payments is being determined.

The research indicated that many states also have large numbers of people with low care needs living in nursing homes, indicating a lack of HCBS access and services. More than 20% of nursing home residents in Rhode Island have low needs – compared to 9% nationally.

Data confirms Major Workforce Crisis in nursing facilities across US

As to nursing homes and institutional care, the AARP’s 2023 Scorecard confirmed that a  major workforce crisis exists in facilities across the country. Across all states, wages for direct care workers are lower than wages for comparable occupations, with shortfalls ranging from $1.56 to $5.03 per hour. In Rhode Island, wages are $1.79 lower than other entry level jobs.   

Nationally, more than 50% of nursing staff in nursing facilities leave their job within a year (53.9% turnover rate). However, in Rhode Island, the rate is slightly better than the average, at 49.3% – with Montana, Vermont, and New Mexico experiencing the highest averages in staffing turnover.  

Staffing disparities are also a significant challenge, say researchers, noting that residents of nursing facilities with high admissions of Black residents receive almost 200 fewer hours of care per year compared to residents of facilities with high admissions of white residents. 

According to the LTSS Scorecard, only 22% of nursing facility residents live in a facility with a 5-star rating in the US – with less than the national average, about 20.2%, of Rhode Island residents living in a 5-star facility. Gaps in workforce and equity result in persistent problems in care, say the researchers. One measure, pressure sores, can be life-threatening as they can lead to bone or joint infections, cancer, and sepsis. In this measure, 10% of facility residents nationwide experienced a pressure sore.

Finally, this year’s Scorecard announced that there is progress being made to create innovative and effective alternatives to traditional nursing facility models. Specifically, the researchers say that 10 states, including Rhode Island, made strides in nursing home innovations, such as by utilizing Green House® Nursing Home availability and policies, which includes small facilities, private rooms, and other best practices.

AARP’s 2023 LTSS Scorecard identified recommendations that can fix the nation’s delivery of long-term care programs and services to enable seniors to age in place in their communities. It called for increasing support to the nation’s 48 million family caregivers, “who are the backbone of the long-term care system, providing over $600 billion in unpaid care, such as with paid leave, tax credits, and other mechanisms to address health and financial needs.”

AARP Rhode Island continues to call on the Rhode Island General Assembly to support the state’s 121,000 family caregivers by advocating for enhancements to the state’s Temporary Caregivers Insurance program.

Recommendations on enhancing Long-Term Services and Supports

The Scorecard’s recommendations also called for investing in states’ Home and Community-based Care Infrastructure, by increasing support and training for home health aides and home visits, supporting the ability to access and use medical devices and equipment, and updating key Medicaid regulations and payment models.  

To tackle the workforce crisis, a recommendation suggests that it is crucial to support both nursing facility and in-home workforce by improving recruitment and training, increasing pay, and expanding the ability of trained nurses, aides, community health workers and other paraprofessionals to take on some aspects of care. States can choose to enact and enforce staffing and related care standards.

A recommendation also calls on States to expand the use of innovative, effective models for nursing homes can improve both quality of care and quality of life, such as with smaller facilities and private rooms and to address inequities by investing to close the staggering gaps in access to quality care and facilities and staffing shortages.

(Editor’s Note:  During the pandemic, then Governor Gina Raimondo allocated $5 million towards 2 changes in nursing homes – making all rooms private and providing non-shared, private bathrooms – for all residents – efforts to follow up on this effort have not resulted in what happened to that initiative according to the RI Department of Health).

Another recommendation urges states to create multisector plans for aging and building of coalitions and age-friendly health systems, to help seniors to age in place at home by having affordable and accessible housing and transportation, improved community design, and comprehensive emergency preparedness plans.

Researchers also suggested the advancing innovation in cities, counties, and states by supporting comprehensive state- and community-wide aging plans and piloting new approaches and programs, like Green House® Nursing Homes and presumptive eligibility, that can then be scaled.

Finally, Climate Change is increasing national disasters, and the LTSS Scorecard recommends that every state have a sound emergency preparedness plan to support nursing home residentsin particular, in times of crisis – including natural disaster.

“AARP’s LTSS Scorecard shows some progress and innovation, but there’s still a long way to go before we have systems that allow people to age well, and independently, for as long as possible and support the nation’s 48 million family caregivers. It’s also clear some emerging issues deserve more attention – from whether nursing homes are prepared to confront natural disasters, to whether they have plans in place to maintain and grow their workforces,” says Susan Reinhard, Senior Vice President, AARP Public Policy Institute.

The LTSS Scorecard is a charitable project made possible by a grant from AARP Foundation, with support from The SCAN FoundationThe Commonwealth Fund, and The John A. Hartford Foundation, and has been updated every three years since 2011.

To view the full Scorecard and state-by-state information visit https://ltsschoices.aarp.org/ 

To view the Scorecard for specifically Rhode Island, go to:  https://ltsschoices.aarp.org/scorecard-report/2023/states/rhode-island.

To view Previous Scorecards (2011, 2014, 2017 and 2020) go to https://ltsschoices.aarp.org/scorecard-report/report-archive/

Increased funding must be tied to nursing home mandated minimum staffing

Published in RINewToday on Sept 25, 2023

The Centers for Medicare and Medicaid Services (CMS) issued a proposed rule to establish comprehensive staffing requirements for nursing homes—including, for the first time, national minimum nurse staffing standards. The proposed rule seeks to would ratchet up the quality of care in the nation’s 18,700 skilled nursing facilities, delivering care to 1.2 million residents each day.

“Establishing minimum staffing standards for nursing homes will improve resident safety and promote high-quality care so residents and their families can have peace of mind,” said HHS Secretary Xavier Becerra in comments on Sept. 1, 2023. “When facilities are understaffed, residents suffer. They might be unable to use the bathroom, shower, maintain hygiene, change clothes, get out of bed, or have someone respond to their call for assistance. Comprehensive staffing reforms can improve working conditions, leading to higher wages and better retention for this dedicated workforce,” says Becerra.

The Nuts and Bolts of CMS’s proposed ruling

Under CMS’s proposal, nursing homes participating in Medicare and Medicaid would be required to meet specific nurse staffing levels that promote safe, high-quality care for residents. Nursing homes would need to provide residents with a minimum of 0.55 hours of care from a registered nurse per resident, per day, and 2.45 hours of care from a nurse’s aide per resident, per day, exceeding existing standards in nearly all states. CMS estimates approximately 75% of nursing homes would have to strengthen staffing in their facilities. As the long-term care sector continues to recover from the COVID-19 pandemic, the proposed standards take into consideration local realities in rural and underserved communities through staggered implementation and exemptions processes.

In addition, nursing homes would also be required to ensure a registered nurse is on site 24 hours a day, 7 days per week, and to complete robust facility assessments on staffing needs. Facilities would continue to be required to provide staffing that meets the needs of the individual residents they serve, which may require higher levels of staffing above the proposed minimum standards.  

CMS also proposed to require states to collect and report on compensation for workers as a percentage of Medicaid payments for those working in nursing homes and intermediate care facilities. These policies build on CMS’ recent proposals to support compensation for direct care workers in home and community based settings and to publish Medicaid data on average hourly pay rates for home care workers. This enhanced transparency will aid efforts to support and stabilize the long-term care workforce across settings strengthening access to high-quality long-term care both at home, in the community as well as in nursing homes and other facilities.

Attracting and supporting Nursing Home staff

Additionally, CMS announced a national campaign to support staffing in nursing homes. As part of the HHS Workforce Initiative, CMS will work with the Health Resources and Services Administration and other partners to make it easier for individuals to enter careers in nursing homes, investing over $75 million in financial incentives, such as scholarships and tuition reimbursement. This staffing campaign builds on other actions by HHS and the Department of Labor to build the nursing workforce.

More than 500,000 direct care workers provide care in nursing homes, assisting residents with daily tasks, such as bathing, dressing, mobility, and eating. This work, often performed primarily by women of color, is significantly undervalued. Direct care workers across long-term care settings earn low wages, rarely receive health and retirement benefits, and experience high injury rates. Improving working conditions and wages will lead to improvements in the recruitment and retention of direct care workers and enable nursing staff to provide safer care.  

CMS and the HHS Office of the Inspector General called for increased transparency and enhance enforcement of existing standards. This would result from increased audits of nursing homes’ staff, improving nursing  home inspections, oversight as to how nursing homes spend taxpayer dollars and cracking down on prescribing inappropriate antipsychotic drug prescribing practices.  The proposed rule would also undertake new efforts to improve resident safety during emergencies. 

Mandating more staffing during a severe labor shortage – pushback on an unfunded mandate

“It is unfathomable that the Biden administration is proceeding with this federal staffing mandate proposal. Especially when just days ago, we learned that CMS’ own study found that there is no single staffing level that would guarantee quality care, says Mark Parkinson, President and CEO of the American Health Care Association, a national nursing home trade group representing 14,000 nursing homes and other long-term care facilities across the nation taking care of five million residents each year.

“At the very same time, nursing homes are facing the worst labor shortage in our sector’s history, and seniors’ access to care is under threat. This unfunded mandate, which will cost billions of dollars each year, will worsen this growing crisis, warns Parkinson, noting that the proposed rule requires nursing homes to hire tens of thousands of nurses that are simply not there and then penalizes the facilities and threatens to displace hundreds of thousands of residents.

“Already, hundreds of nursing homes across the U.S. have closed because of a lack of workers,” states Parkinson. 

John E. Gage, President, and CEO of the Rhode Island Health Care Association, with offices in Warwick, agrees with Parkinson’s assessment of the harm such proposals will trigger and its devastating impact on nursing homes and residents. “The federal staffing proposal is unfunded and is being implemented at a time when additional staff is simply not available,” he said.  

According to Gage, six Rhode Island-based facilities have closed since the beginning of the pandemic in March 2020. Three others are currently in receivership. Arbitrary federal staffing mandates will result in more closures, and residents will be displaced from their homes just as they were most recently when Charlesgate Nursing Center in Providence was forced to close because of skyrocketing costs, a scarcity of staff and chronically inadequate Medicaid funding. 

Unintended consequences of mandating minimum staffing

James Nyberg, president, and CEO of LeadingAge Rhode Island, with offices in East Providence, views see a staffing ratio mandate as a blunt enforcement instrument that does not consider the numerous challenges facing providers, including Medicaid underfunding, lack of workforce, and the diversity of resident needs. Moreover, the imposition of severe financial penalties on homes that are unable to meet a staffing ratio is counterproductive: fines siphon off scarce resources that providers need as they seek to address their workforce and resident care needs,” he says. 

“Our state’s experience illustrates the numerous challenges and unintended consequences of a staffing ratio mandate: the severity of fines, how compliance is measured and calculated, compliance costs, backlogs of people in hospitals waiting for skilled nursing care after admissions have been reduced due to a lack of staff and other access-related issues,” notes Nyberg, noting that even those homes that are currently able to comply with the staffing ratio are doing so at an unsustainable cost. 

While Kathleen Heren, executive director of the Alliance for Better Long-Term Care and the state’s Long-Term Care Ombudsman, supports HHS’s minimum staffing standard, the administration must adequately fund to train recruited workers and to pay a livable wage to retain them. “Rhode Island doesn’t have an issue with its nursing home inspection process as other states do, she says, noting that newly hired RI Department of Health surveyors are “doing a great job.” 

“RIDOH surveyors only cite facilities, when necessary,” says Heren, noting that administrators can challenge any cited deficiency if they view it as unfair, and she doesn’t see a problem in the use of antipsychotic medications in Rhode Island facilities “but acknowledges that there’s always room for improvement.”

Direct Caregivers, mainly women, undervalued despite significant work demands

“Almost 80 percent of nursing home care is paid for with government programs (Medicare and Medicaid), so it is hugely important that those dollars provide quality care,” says Maureen Maigret, chairperson of the aging in community subcommittee for the Long Term Care Coordinating Council.  She noted that studies show a clear relationship between staff levels and quality care but there is tremendous variation across the states in hours of direct care staff provided in nursing homes. 

“Rhode Island has required 24/7 RN staffing for many years and a 2021 state law requires minimum direct care staffing levels although implementation has been challenging due to the critical workforce shortage. Importantly, the proposed federal regulation would require states to report on compensation for workers as a percentage of Medicaid payments. For too long our direct care workers, mostly women, have been undervalued despite the significant demands of their work. It is time for them to receive a living wage and  shedding light on where our Medicaid dollars are going will help advocate for better wages helping to recruit and retain these essential workers,”  she says.

There will be a 60-day comment period for the notice of proposed rulemaking, and comments must be submitted to the Federal Register no later than November 6, 2023.  

For a copy of the federal register detailing CMS’s proposed rules on minimum staffing issued on Sept. 6, 2023, go to 

https://www.govinfo.gov/content/pkg/FR-2023-09-06/pdf/2023-18781.pd

For a copy of a CMS Fact Sheet on CMS’s proposed rules on minimum staffing, go to https://www.cms.gov/newsroom/fact-sheets/medicare-and-medicaid-programs-minimum-staffing-standards-long-term-care-facilities-and-medicaid