Jacquelyn McCarthy, who runs a nursing home in Framingham, Mass., credits the five-star rating it's getting from the government today to its focus on caring for both residents and staff.

The Bethany Health Care Center, a 169-bed nonprofit home sponsored by the Sisters of St. Joseph, is one of 33 nursing homes nationwide to earn top ratings across all categories in scores posted on a federal government Web site. McCarthy says giving workers health insurance, pensions and low-cost meals pays off. Turnover is low, and nursing assistants care for the same people each day, allowing them to get to know residents.

"If the resident doesn't seem as alert or if it looks like they're more agitated, we know immediately and can get right on it," says McCarthy, whose facility earned five stars overall and in categories on staffing, inspection results and quality measures. The Centers for Medicare & Medicaid Services scored nearly 16,000 nursing homes for the first time.

Lower in the ratings is Oakwood Healthcare in Philadelphia, one of six nursing homes nationwide regarded as so troubled by Medicare that it was tagged as one of the nation's worst for nearly four years. Eight months of improvements helped net the home two stars.

"I think the reputation was deeply deserved," says Irene Contino-Kosyla, who became Oakwood's administrator in April as part of an overhaul by new owners. The 148-bed facility was run-down, badly managed and dealt with difficult patients by putting far too many on mood-altering drugs, she says.

The new ratings reflect a Bush administration effort to promote openness about quality, aiming to increase competition among nursing homes and give consumers more choice.

Nursing homes face daunting challenges: finding and keeping staff, caring for frail patients, complying with a host of federal and state rules and doing it all under financial constraints imposed by limited government payments that vary from state to state. As a result, quality varies widely among individual homes and among states, according to an analysis of the Medicare ratings by USA Today.

In 14 states, residents choosing a home randomly have a more than 25 percent chance of picking a nursing home that, overall, rates one star, the lowest ranking on Medicare's new system.

USA Today also found that: