Editors’ note: SAGE will present findings from its 2026 POE of LiveWell River Homes and Resilient Living Center, recipient of the 2025 EFA Design Showcase Award of Merit, at the 2026 EFA Conference + Expo, on Wednesday, March 18, during the session “Notes from the Field: A SAGE Post-Occupancy Evaluation.” For more on the EFA Conference schedule, go here.
Migette Kaup (Courtesy of SAGE)
For many long-term care communities, the greatest challenge is anticipating the future. At the Flandreau Santee Sioux Tribe (FSST) Care Center in Flandreau, S.D., that future looks different than originally expected.
Designed as a culturally grounded long-term care facility for tribal elders, the 42-bed community now serves a younger, medically complex population shaped by trauma, disability, and changing care needs.
In 2025, the Society for the Advancement of Gerontological Environments (SAGE) conducted a post-occupancy evaluation (POE) of the FSST Care Center to better understand how the building’s design intent is performing in practice.
The interdisciplinary team included POE team leader Amy Carpenter, partner, Design4Age Strategic Advisors (Glenside, Pa.), and research coordinator Migette Kaup, professor of interior design, Kansas State University (Manhattan, Kan.), along with team members Lisa Warnock, principal and founder, Glow Interior Designs (Portland, Ore.); Grant Warner, senior housing practice leader, BKV Group (Minneapolis); and Jeffery Beegle, senior director of project development, Three Pillars Senior Living Communities (Milwaukee).
The team was joined on site by Ryan Turner, principal and director of healthcare design, DSGW Architecture (Duluth, Minn.), and lead project architect for the FSST Care Center.
What emerged was a compelling case study in culturally resonant design—one that also reveals the balance between symbolism, operations, and the realities of care delivery.
Understanding the SAGE POE process
The POE was conducted using SAGE’s established framework, a structured yet flexible approach developed and refined through more than two decades of evaluations in senior living and long-term care settings. The process is designed to assess how well a built environment supports residents, staff, and operations after occupancy, with particular attention to person-centered care, environmental fit, and real-world use.
The evaluation at the FSST Care Center employed an indicative-level POE, which combines qualitative and observational methods. An interdisciplinary SAGE team conducted an on-site visit in April 2025 that included structured interviews with leadership, direct care staff, and residents.
Additionally, the team employed systematic walk-throughs of residential households, shared spaces, support areas, and outdoor environments. Observations focused on spatial organization, lighting, acoustics, materials, wayfinding, safety, and operational workflows.
Design intent documentation and preoccupancy materials were also reviewed to understand original goals and assumptions. By considering stakeholder perspectives with environmental observations, the POE process allows strengths and challenges to be understood in context.
This process is intended to provide actionable insights that extend beyond this single project to inform future long-term care design.
Cultural meaning embedded in architecture
Completed in 2022 and designed by DSGW Architecture (Duluth, Minn.), the FSST Care Center is organized around a household model. From the outset, tribal symbolism shaped the building’s form, materials, and spatial relationships.
Specifically, the site and building layout reference the Medicine Wheel, with three residential wings oriented toward cardinal directions and connected by a central administrative core.
Each household wing conveys distinct cultural meaning through color, material, and orientation. For example, local catlinite stone, traditionally used to craft ceremonial pipes, appears throughout the facility, from exterior stonework to interior fireplaces and memorial elements. Wood ceiling patterns evoke the fletching of arrows, while diagonal detailing and natural finishes reinforce a connection to land and tradition.
At the heart of the building is a multipurpose room designed for ceremony and gathering. Its conical ceiling recalls a teepee form, punctuated by a skylight and surrounded by wood poles. The floor pattern references a star quilt, a powerful symbol in Dakota culture.
Throughout the building, residents are referred to as “relatives,” reinforcing kinship-centered values and a shared sense of belonging.
These elements are not decorative gestures; they are deeply meaningful. Residents and staff expressed pride in the cultural grounding of the space, noting that ceremonies such as weekly smudging rituals provide spiritual comfort and continuity.
Addressing changing resident demographics in senior living
While the FSST Care Center was envisioned as an elder-focused community, the population it now serves reflects a much broader and younger demographic. Many residents are under 50, living with traumatic brain injury, paralysis, or substance-related cognitive impairment.
The household model has proven to be a critical strength. Residents with diverse needs benefit from the flexibility of private rooms with generous dimensions, full bathrooms, deep window seats, and individual climate controls allowing them to choose a comfortable room temperature.
At the same time, certain design decisions, particularly those influenced by value engineering, have created operational challenges, including the removal of ceiling-mounted lifts and problematic flooring transitions between bedroom and bathroom spaces.
The POE also highlighted the complex interplay between cultural practice, regulation, and operations. Tobacco and smudging ceremonies, both deeply significant, have been accommodated through thoughtful operational protocols and close coordination with code officials.
Outdoor access and dining flexibility, however, remain areas where cultural values and operational practices are still evolving to find the right balance.
Lessons for future design
The FSST Care Center demonstrates both the power and the complexity of culturally grounded long-term care design. Its strengths lie in meaningful symbolism, generous private spaces, and a household model capable of absorbing unexpected demographic shifts.
Its challenges underscore the importance of aligning design, operations, and evolving care realities.
Learn more about SAGE POEs and access resources (including the 2025 SAGE white paper) here.
Migette Kaup, PhD, EDAC, NCIDQ, is a professor of interior design at Kansas State University (Manhattan, Kan.) and can be reached at [email protected].
