Association of Nursing Home Exposure to Hurricane-Related Inundation With Emergency Preparedness.

Importance: Whether US nursing homes are well prepared for exposure to hurricane-related inundation is uncertain. Objectives: To estimate the prevalence of nursing homes exposed to hurricane-related inundation and evaluate whether exposed facilities are more likely to meet Centers for Medicare & Medicaid Services (CMS) emergency preparedness standards. Design, Setting, and Participants: This cross-sectional study included CMS-certified nursing homes in Coastal Atlantic and Gulf Coast states from January 1, 2017, to December 31, 2019. The prevalence of facilities exposed to at least 2 feet of hurricane-related inundation used models from the National Hurricane Center across coastal areas overseen by 5 CMS regional offices: New England, New York metropolitan area, Mid-Atlantic region, Southeast and Eastern Gulf Coast, and Western Gulf Coast. Critical emergency preparedness deficiencies cited during CMS life safety code inspections were identified. Main Outcomes and Measures: The analysis used generalized estimating equations with binomial and negative binomial distributions to evaluate associations between exposure status and the presence and number of critical emergency preparedness deficiencies. Regionally stratified associations (odds ratios [ORs]) and rate ratios [RRs]) with 95% CIs, adjusted for state-level fixed effects and nursing home characteristics, were reported. Results: Of 5914 nursing homes, 617 (10.4%) were at risk of inundation exposure, and 1763 (29.8%) had a critical emergency preparedness deficiency. Exposed facilities were less likely to be rural, were larger, and had similar CMS health inspection, quality, and staffing ratings compared with unexposed facilities. Exposure was positively associated with the presence and number of emergency preparedness deficiencies for the nursing homes within the Mid-Atlantic region (adjusted OR, 1.91 [95% CI, 1.15-3.20]; adjusted RR, 2.51 [95% CI, 1.41-4.47]). Conversely, exposure was negatively associated with the number of emergency preparedness deficiencies among facilities within the Western Gulf Coast (aRR, 0.55 [95% CI, 0.36-0.86]). The associations for the number of emergency preparedness deficiencies remained after correction for multiple comparisons. Conclusions and Relevance: The findings of this cross-sectional study suggest that the association between exposure to hurricane-related inundation and nursing home emergency preparedness differs considerably across the Coastal Atlantic and Gulf regulatory regions. These findings further suggest that there may be opportunities to reduce regional heterogeneity and improve the alignment of nursing home emergency preparedness with surrounding environmental risks.

Evaluating California nursing homes' emergency preparedness for wildfire exposure.

BACKGROUND: The relationship between the risk of exposure to environmental hazards and the emergency preparedness of nursing homes is not well-understood. This study evaluates the association between wildfire exposure risk and nursing home emergency preparedness. METHODS: From a sample of Centers for Medicare & Medicaid Services (CMS) certified nursing homes in California, we determined the prevalence of "exposed" facilities that were located within 5 km of a wildfire risk area, as informed by a field-tested model. Among the 1182 nursing homes, we identified emergency preparedness deficiencies from January 2017 to December 2019. We estimated associations between exposure and emergency preparedness deficiencies using unadjusted and adjusted generalized estimating equations with logistic and negative binomial distributions. RESULTS: A greater percentage of the 495 exposed facilities had at least one emergency preparedness deficiency than the 687 unexposed facilities (83.9% vs 76.9%). The mean (3.6 vs 3.2) and median (3 vs 2) numbers of emergency preparedness deficiencies were also greater for exposed facilities. In both the unadjusted and adjusted analyses, exposure to wildfire risk was significantly associated with the likelihood of at least one emergency preparedness deficiency (adjusted odds ratio 1.52, p-value 0.007). There was a positive but not statistically significant association between exposure and the number of emergency preparedness deficiencies assigned to a nursing home (adjusted rate ratio 1.12, p-value 0.062). These results were consistent in analyses that used more stringent distance- and severity-thresholds to define exposure status. CONCLUSION: California nursing homes at heightened risk of exposure to wildfires have poorer emergency preparedness than unexposed facilities. These findings suggest that nursing home management and staff may be unaware of important environmental risks to which their facilities are exposed. Improved integration of nursing homes into community disaster planning may better align facility preparedness with surrounding wildfire risk.

Replicated radiation of a plant clade along a cloud forest archipelago.

Replicated radiations, in which sets of similar forms evolve repeatedly within different regions, can provide powerful insights into parallel evolution and the assembly of functional diversity within communities. Several cases have been described in animals, but in plants we lack well-documented cases of replicated radiation that combine comprehensive phylogenetic and biogeographic analyses, the delimitation of geographic areas within which a set of 'ecomorphs' evolved independently and the identification of potential underlying mechanisms. Here we document the repeated evolution of a set of leaf ecomorphs in a group of neotropical plants. The Oreinotinus lineage within the angiosperm clade Viburnum spread from Mexico to Argentina through disjunct cloud forest environments. In 9 of 11 areas of endemism, species with similar sets of leaf forms evolved in parallel. We reject gene-flow-mediated evolution of similar leaves and show, instead, that species with disparate leaf forms differ in their climatic niches, supporting ecological adaptation as the driver of parallelism. Our identification of a case of replicated radiation in plants sets the stage for comparative analyses of such phenomena across the tree of life.