Of all the rules in daily management at the United Living Community nursing home, one stands out for man and beast.
"The cats own the place," administrator Sally Damm said.
Toby, a 3-year-old dog resembling both Dalmatian and basset hound, makes the best of this rule. He gives space to the half-dozen cats that are co-residents and then goes where he pleases.
It's not unusual to see dogs and cats at South Dakota's 111 nursing homes. Nor is it strange to see young children there mingling with the elderly.
But the United Living center has both under one roof. The animals are honorary residents. The 120 children spend their day in the day care center down the hall and make daily visits to see their older friends.
"There are 17,000 nursing homes in the U.S., and less than 100 facilities that have a child-care center attached," Ms. Damm told the Argus Leader. "Add the dogs and cats and birds living in the nursing home, and you're down to about 50, to the best of my knowledge. It's not something I can Google and prove to you, but we are pretty rare."
So it is a fact of life that the recent open house to christen a $6.1 million upgrade at United Living Community was as much a salute to innovative thinking as it was an occasion to showcase the remodeling and new construction.
It costs $5,000 a month or $60,000 a year to house one resident in a nursing home in this state, said Mark Deak, executive director of the South Dakota Healthcare Association. That works out to $6.84 an hour, "which is pretty cost-effective health care," he said.
The costs squeeze almost every nursing home budget and are coupled with a notoriously high turnover rate for workers. That forces managers to be resourceful as they provide amenities that a new generation of retirees is demanding in a setting that residents and their families will find comforting.
"We all know the expectations of residents of nursing and assisted-living facilities, particularly in creating a more inviting atmosphere," Mr. Deak said. "What the providers have discovered is that introducing pets is much like something you would do in your own home."
In Estelline, a community of 700 between Brookings and Watertown, the Estelline Nursing Home and Care Center has tried to make the most of all available resources, said administrator Michael Ward.
"We have a barnyard with a horse, two goats and three chickens, doves and rabbits," Mr. Ward said. "Many residents come from a farm. One guy said 'even the smell of manure reminds me of home.'"
Sixth-graders from the Sharon Delzer Elementary School in Estelline visit the 60-bed nursing home every Friday. High school band and chorus members are regular performers there, and each year the junior and senior proms start with dinner in the nursing home dining room. The town needs the nursing home, with its 72 employees, and the two generations need each other when they meet at the nursing home, he said.
"It gets rid of the stigma about old people ... and I get great employees because a lot of school kids want to come back and work here," Ward said.
In Brookings, two nursing homes each completed major building projects this year.
Brookview Manor, which the city owns and operates, opened a new $15 million campus in June that is built for luxury and privacy in a community setting, said administrator Jason Hanssen.
The new center has the same capacity of 79 rooms, in keeping with the state moratorium on skilled-care beds, but in a building three times the size of the old one. It has 73 private rooms and three rooms for couples, compared to the previous layout where half the rooms were private. They are arranged in what management calls six households, each with 13 rooms where residents share a living room, dining room, courtyard, kitchen, and spa. The households unite around a town center, theater, chapel, and park. Private-pay residents spend $5,400 to $9,100 a month to live there.
"Everybody wants their space and their privacy," Mr. Hanssen said.
Across town, the United Living Community has done similar things, if on a smaller scale, in the project it is dedicating today.
United Living has 81 skilled-care beds. That total includes 39 private rooms, up from 21 before the project, and 21 double-occupancy rooms. The center also has new neighborhoods to break residents into smaller groups, each with a kitchen and eating area. The old dining hall, once where everyone ate lunch, is now a meeting space and chapel.
The center has its share of modern touches. A fidget board in the memory unit is a gadget with locks, latches and water faucets to help residents reconnect with activities of the past. A new spa with floor-level entry is essentially a $10,000 bathtub, but a device worth the price because of the ease it brings to daily hygiene, Damm said.
Damm, 58, is a 1973 Lemmon High School graduate. She earned degrees at Huron College and the University of South Dakota and has been in nursing home work for 37 years, starting as a certified nurse assistant at the Five Counties home in Lemmon.
She manages a $7 million annual budget at United Living, a private nonprofit, a budget that includes $750,000 for the day-care center. Embedded in the budget are unequal rates. Private-pay residents, about 50 percent of the population at the center, pay $182 a day on average to stay at the center. They subsidize residents on Medicaid, about 38 percent of the total, who bring in only $115 a day, according to the government's formula. She has 210 full- and part-time employees and a 47 percent annual turnover on her staff.
A few intangible factors help compensate for the difficult math.
One is generosity from surprise places. At the front of the chapel are a wooden altar, pulpit and baptismal font, all dating to 1892, which the Oslo Lutheran Church south of Volga donated this year to the nursing home.
Clara Hegg, 101, one of the residents, told Damm when she saw it, "I can be a kid again. This is like the altar where I was confirmed."
Another is the feeling of home, which, if a center can pull it off, is immeasurable. Damm toured the center with the ever-officious Toby, who ran ahead to bark at residents. Toby leapt onto the lap of Myrl Bruemmer, 88, a retired farmer, and slathered his face with multiple licks.
Next to one of the kitchens, 10 children arrived at 11 a.m. from the day-care wing. They gathered in a circle with three elderly women and used a red, yellow, green, and blue tarp to keep afloat a series of balloons that Barb Caulfied, one of the managers, placed in the middle of the tarp. That was a diversion to break up the morning but also 10 minutes of upper body exercise for children and adults alike.
"It gives them a lift for their day," said Sherry Oswald, director of the child-care center.
Damm summed it up differently.
"You can go to physical therapy and pay $80 to work with a pulley, or you can do this," she said.
In the entire tour, Toby encountered just one of the cats. They stared at each other briefly. Toby is not a hit with everybody, so Damm occasionally must run interference. It's not a big concern. She's brought in llamas and fainting goats in other situations. She's not about to overreact if somebody doesn't care for the dog.
"This is life. Life happens here," she said. "Animals and children do more for residents than any medications in a bottle."