Catalina Post Acute And Rehabiliation

    2611 North Warren Avenue, Tucson, AZ, 85719
    2.5 · 18 reviews
    • Memory care
    • Skilled nursing
    AnonymousLoved one of resident
    1.0

    Neglect, missed meds, alarming lapses

    I appreciated that many staff were polite and helpful, therapy/OT/PT often helped, and the food and dog visits were okay - but my overall experience was alarming. Call lights and phones frequently went unanswered, I (or my loved one) was left in a wheelchair/hallway for hours, hygiene was neglected (soiled bedding, inconsistent showers), meds and wound care were missed, and therapies were stopped or poorly coordinated. There were dangerous lapses (oxygen/ambulance mismanagement, delayed care that led to decline/ICU), and administration offered excuses instead of fixes. Despite friendly people, the systemic failures and terrible communication mean I would not trust this facility with a medically vulnerable family member.

    Pricing

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    Amenities

    Healthcare services

    • Activities of daily living assistance
    • Assistance with bathing
    • Assistance with dressing
    • Assistance with transfers
    • Coordination with health care providers
    • Medication management
    • Mental wellness program

    Healthcare staffing

    • 12-16 hour nursing
    • 24-hour call system
    • 24-hour supervision

    Meals and dining

    • Diabetes diet
    • Meal preparation and service
    • Special dietary restrictions

    Room

    • Air-conditioning
    • Cable
    • Fully furnished
    • Housekeeping and linen services
    • Kitchenettes
    • Private bathrooms
    • Telephone
    • Wifi

    Transportation

    • Community operated transportation
    • Transportation arrangement
    • Transportation arrangement (medical)
    • Transportation arrangement (non-medical)
    • Transportation to doctors appointments

    Common areas

    • Beauty salon
    • Computer center
    • Dining room
    • Fitness room
    • Gaming room
    • Garden
    • Outdoor space
    • Small library
    • Wellness center

    Community services

    • Concierge services
    • Fitness programs
    • Move-in coordination

    Activities

    • Community-sponsored activities
    • Planned day trips
    • Resident-run activities
    • Scheduled daily activities

    2.50 · 18 reviews

    Overall rating

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1
    • Care

      2.2
    • Staff

      2.6
    • Meals

      2.4
    • Amenities

      1.8
    • Value

      1.0

    Pros

    • Friendly, polite or accommodating staff (reported by multiple reviewers)
    • Conscientious and skilled caregivers in some cases
    • Effective OT/PT/rehabilitation services reported by some families
    • Therapy room and staff that helped with strength and recovery (for some residents)
    • Good or surprisingly good food reported by several reviewers
    • Clean center and no odor reported by some reviewers
    • Wheelchair-accessible seating and quality furniture
    • 24/7 care and attentive care reported in positive reviews
    • Helpful feeding assistance and support in certain cases
    • Dog-friendly visits and welcoming atmosphere for some visitors
    • Good location and convenient facility layout
    • Some reviewers would recommend and had pleasant stays

    Cons

    • Strong urine odor reported in many areas
    • Unmanned reception and no staff in sight at times
    • Unwelcoming, rude, or unprofessional staff reported
    • Call lights ignored or long delays answering call buttons
    • Overcrowded, small two-person rooms
    • Long waits for staff response (examples 6+ hours, 9–11 pm)
    • Administration frequently absent or unavailable
    • Infrequent care checks and inconsistent hygiene assistance
    • Inconsistent or missed showers and bathing
    • Therapies not performed daily or stopped unexpectedly
    • Non-working phone numbers and daily phone outages
    • Poor family-staff communication and lack of transparency
    • Multiple families expressed concerns about care quality
    • Serious clinical failures: patients sent to ICU or condition worsened
    • Security issues: malfunctioning main entrance doors, doors left open
    • Inadequate staff training and disorganized care delivery
    • Allegation of CNA hitting a patient
    • Medications not given on time or missed
    • Wounds not cleaned or dressed; bedsores and poor wound care
    • Residents left in dirty diapers or fecal matter hygiene issues
    • Feeding assistance lacking; food trays shoved in some cases
    • Facility appears unequipped for acute care needs
    • Patient death soon after discharge from facility reported
    • Misrepresentation of rooms or windows
    • Disorganized, dysfunctional management and passing-the-buck
    • Documentation issues and unclear medical explanations
    • Failure to call ambulance or manage oxygen and emergencies
    • Residents left unattended in hallways or wheelchairs for hours
    • No posted doctor schedule or nurse/aid rotations; scheduling opacity
    • Security and safety concerns prompting calls for regulatory review

    Summary review

    Overall sentiment across the reviews is highly mixed, with a significant divide between reports of attentive, effective rehabilitation care and multiple severe complaints of neglect, poor communication, and safety lapses. A cluster of reviewers described positive experiences: staff who were friendly, polite, accommodating and in some cases very skilled; therapy teams (OT/PT) that helped residents regain strength; good or surprisingly good meals; and clean, wheelchair-accessible communal spaces. Several accounts emphasize successful rehabilitative outcomes, 24/7 monitoring, and a welcoming environment that felt like home for some residents.

    However, a substantial and recurring set of negative themes appears across many summaries and is serious in nature. The most common operational problems are absent or unresponsive staff, ignored call lights, long delays in assistance (reported waits of multiple hours and late-night shortages), and poor hygiene practices including inconsistent showers, residents left in soiled diapers, and urine/fecal odor in hallways and rooms. Multiple reviews describe inadequate wound care and documentation, with specific reports of bedsores, untreated wounds, and even cases where a patient’s condition worsened and led to ICU transfer or death shortly after discharge. These clinical failures raise concern about the facility’s ability to manage higher-acuity patients.

    Communication and administrative problems are another consistent pattern. Reviewers report non-working phone lines, difficulty reaching administrators or the nursing director, lack of posted schedules for doctors and nursing aides, and family members being left without clear information about medical or therapy plans. Several accounts describe management excuses, buck-passing, and a general lack of transparency—examples include unexplained discharges to independent living, unclear therapy schedules, and no visible coordination among staff teams. Security and safety issues—malfunctioning main entrance doors, unmanned reception, and patients left unattended in hallways—were reported and contribute to an impression of lax oversight.

    There is also a stark inconsistency in care quality from reviewer to reviewer. While some experienced professional, attentive nursing and strong rehabilitation programming, others described staff incompetence, alleged abuse, missed medications, halted therapy services, and logistical breakdowns (phones down daily, crowding in two-person rooms, messy or disgusting rooms). Dining experiences were similarly split: several reviewers praised the food, while others called it disgusting or complained about lack of assistance with meals. Facility cleanliness reports were mixed—some described a very clean center with nice furnishings; others reported urine smell, soiled bedding, and dirty rooms.

    Taken together, the reviews suggest the facility may function well for certain residents—particularly those needing standard rehabilitation and with consistent staff support—but that significant variability in staffing, training, and management oversight creates risks for others, especially higher-acuity patients. Recurrent themes of ignored call lights, delayed responses, wound-care failures, communication breakdowns, and safety/security lapses warrant careful attention. For prospective families, these patterns indicate it is important to verify current staffing levels, infection and wound-care protocols, emergency procedures, phone and security system reliability, and to obtain recent references. For regulators or oversight bodies, the documented reports of serious clinical deterioration, alleged abuse, and safety failures suggest a need for targeted evaluation and monitoring. Overall, while there are positive pockets of care, the frequency and severity of the negative reports are significant and should guide cautious evaluation and close monitoring if choosing this facility.

    Location

    Map showing location of Catalina Post Acute And Rehabiliation

    About Catalina Post Acute And Rehabiliation

    Catalina Post Acute & Rehabilitation sits in a quiet area of Tucson, AZ, at 2611 N Warren Ave, offering 102 certified beds in a single-story building with both private and semi-private rooms. Managed by Robert Eagar since 2009 and owned by Bandera Healthcare LLC, the facility ties to The Ensign Group and focuses mainly on short-term rehabilitation and long-term skilled nursing care, supporting people after surgeries, strokes, or joint replacements, and those who need ongoing help such as wound care, dialysis services, or 24-hour respiratory therapy. The staff provides physical, occupational, and speech therapy on-site, including the Advanced Integrated Cognitive Program for residents facing memory loss. Residents take part in exercise classes, arts programs, lectures, and social events, with outings, worship services, and a range of activities such as cards, games, and movies, so there's something to fit many interests. Wi-Fi runs throughout the building, the dining room gets plenty of light, and walking paths and patios offer time outdoors, which many enjoy, while the rooms look comfortable and the grounds stay well-kept. Housekeeping, laundry, and transportation services help with daily living, while staff give assistance with bathing, dressing, and grooming. Apartment types include studio and companion units. The nurse staffing level stands at 3.86 hours per resident per day, which falls a bit below the state average. Nurse turnover is higher than average at 48.5%. In recent inspections, Catalina Post Acute & Rehabilitation received 17 noted deficiencies, including some for resident rights, quality of life and care, and infection control. The facility currently holds a 4-star overall rating from Medicare.gov, but it's had its share of challenges, and it pays attention to cleanliness and maintaining a pleasant, homelike space, with access to a full range of therapies and a team that puts effort into individual care plans involving residents and families. At this time, the facility isn't accepting new patients, but for those staying, amenities and care aim to meet varied needs while keeping things steady and safe, as much as possible.

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