Harold Labrensz spent much of his 89-year life farming and ranching the rolling Dakota plains along the Missouri River. His family figured he would die there, too.
But late last year, the nursing home in Mobridge, S.D., that cared for Mr. Labrensz announced that it was shutting down after a rocky history of corporate buyouts, unpaid bills and financial ruin. It had become one of the many nursing homes across the country that have gone out of business in recent years as beds go empty, money troubles mount and more Americans seek to age in their own homes.
For Mr. Labrensz, though, the closure amounted to an eviction order from his hometown. His wife, Ramona, said she could not find any nursing home nearby to take him, and she could not help him if he took a fall at home. So one morning in late January, as a snowstorm whited out the prairie, Mr. Labrensz was loaded into the back of a small bus and sent off on a 220-mile road trip to a nursing home in North Dakota.
“He didn’t want to go,” said Mrs. Labrensz, 87, who made the trip with her husband. “When we stopped for gas, he said, ‘Turn this thing around.’ ”
More than 440 rural nursing homes have closed or merged over the last decade, according to the Cowles Research Group, which tracks long-term care, and each closure scattered patients like seeds in the wind. Instead of finding new care in their homes and communities, many end up at different nursing homes far from their families.
In remote communities like Mobridge, an old railroad town of 3,500 people, there are few choices for an aging population. Home health aides can be scarce and unaffordable to hire around the clock. The few senior-citizen apartments have waiting lists. Adult children have long since moved away to bigger cities.
“How often have you heard somebody say, ‘If I go to a nursing home, just shoot me?’” said Stephen Monroe, a researcher and author who tracks aging in America. “In the rural areas, you don’t have options. There are no alternatives.”
The relocations can be traumatic for older residents, and the separation creates agonizing complications for families. Relatives say they have to cut back visits to one day a week. They spend hours on the road to see their spouses and parents.
“Before, I could just drop by five days a week,” said the Rev. Justin Van Orman, a Lutheran pastor who moved back to Mobridge to be closer to his 79-year-old father, Robert. “He knew I was there.”
Not long after Mr. Van Orman’s father moved from Mobridge to a new nursing home about 50 miles away, Mr. Van Orman got a call saying his father had fallen out of bed. Mr. Van Orman had to decide: Should he upend his day to check on him, or wait and take the nursing home’s word that his father was O.K.?
Similar scenes are playing out in other heavily rural states. Five nursing homes closed in Nebraska last year, with more at risk of closing. Six shut down in Maine — a record, according to the Bangor Daily News.
Thirty-six rural nursing homes across the country have been forced to close in the last decade because they failed to meet health and safety standards. But far more have collapsed for financial reasons, including changing health care policies that now encourage people to choose independent and assisted living or stay in their own homes with help from caregivers.
Some nursing homes cannot find people to do the low-paying work of caring for frail residents. Others are losing money as their occupancy rates fall and more of their patients’ long-term care is covered by Medicaid, which in many states does not pay enough to keep the lights on.
South Dakota chips in less than any other state in the nation to pay for long-term care for residents on Medicaid, said Mark B. Deak, executive director of the South Dakota Health Care Association. He added that the state’s low payment level — a product of South Dakota’s fiscal conservatism and distrust of government-run health care — has now created a crisis.
Five South Dakota nursing homes have shut down in the past three years, and dozens more are losing money because the majority of their residents rely on Medicaid. At current reimbursement rates, nursing homes in the state lose about $58 a day for each resident on Medicaid, Mr. Deak said. It adds up to $66 million a year in losses statewide.
“The state has not held up its obligation to seniors,” Mr. Deak said. “How many more nursing homes closing is it going to take?”
Gov. Kristi Noem has proposed a 5 percent increase in the state’s Medicaid reimbursement rate. Mr. Deak said that would not be nearly enough to cover the losses.
The 89-bed Mobridge Care and Rehabilitation Center was rated overall as “below average” by Medicare’s Nursing Home Compare program, though for patient care, the home received four out of five stars in the agency’s assessment. The brown brick building was getting old, and had been damaged by a bad summer storm in 2018.
The nursing home had been part of a chain that switched hands and foundered financially, ultimately ending up in court-appointed receivership. In November, the receiver told a South Dakota judge that the chain’s operations were bleeding money, and that it needed to close down the two homes in the chain that were deepest in the red. Mobridge was one.
The South Dakota Department of Health did not object, and the judge agreed to the closure. Word began to spread through the home and through town: The residents had about two months to find somewhere else to go.
Black Hills Receiver, which had taken over operation of the nursing home, said in a November statement announcing the closure that it was working with residents, their families and employees “to make this transition as smooth as possible.” The company declined an interview request.
On paper, South Dakota and other rural states still have enough long-term care beds for people who need round-the-clock care. The problem is where they are. When a nursing home closes in a small town, the available beds are often so far away that elderly spouses cannot make the drive, and the transferred residents become cut off from the friends, church groups and relatives they have known all their lives.
Even the closest town can feel as though it is a world away when a blizzard rakes across the prairie and turns the two-lane road out of Mobridge into a billowing scarf of snow.
For six days this winter, Loretta Leonard could not make the 20-mile drive to see her husband, Dick, who is 91 and suffers from severe dementia, at his new nursing home. When he was living close by at the Mobridge home, she often visited him twice a day, sitting down at the piano to play the old polkas and hymns and Depression-era tunes their daughters sang growing up.
“He always knew me,” Ms. Leonard, 88, said. “Sometimes I wonder whether he knows me anymore.”
The part-time bus driver for the Mobridge nursing home began keeping a list as he dropped people at their new homes: “Residents Who Left.” One resident was moved to Aberdeen, 100 miles east. A husband and wife went 73 miles down Highway 12 to Ipswich. Roommates said goodbye. Fast friends landed in different homes. One person ended up in Nebraska.
“Like cattle,” said Nadine Alexander, a certified nursing assistant who worked at the Mobridge nursing home for 29 years. “They were just hauling them out.”
On the snowy day that Harold Labrensz left Mobridge for his new nursing home in North Dakota, not even the bus driver wanted to make the trip. For seven hours, they crept north along icy roads before arriving.
Mrs. Labrensz chose the facility because it was close to her son’s home, and she was able to find a small efficiency apartment just across the street from the nursing home. They spent 68 years together working their land, fishing and raising a family, and Mrs. Labrensz said she wanted to stay close.
“We spent our whole life together,” she said.
She was also close by when, three days after arriving in North Dakota, Mr. Labrensz died. The date was Jan. 31 — the same day that, 220 miles away, the Mobridge nursing home officially closed its doors.