5
Inspections
4
Deficiencies
0
Actual Harm or Above
2
Occurrences
November 4, 2025
Last Inspection
S/S B Minimal potential
The most recent inspection of GOLDEN HORIZON on record is dated November 4, 2025. Across 5 published inspections, state surveyors cited 4 deficiencies, none of which reached the actual-harm level.
Colorado publishes inspections on a rolling window, so older surveys may no longer appear. Citation codes 0000 and 9999 are the surveyor's opening and closing comments, not deficiencies, and are excluded from the counts above. Where the state required one, the facility's own plan of correction is shown beneath the finding it answers.
Provider Information
Status
Active
Facility Type
Assisted Living Residence/Alternative Care Facility (Medicaid)
Administrator
HARRIMAN, JOSEPHINE
Owner
GOLDEN GATE MANOR INC
Phone
(719) 564-8110
Payor Source
Medicaid, Private Pay
City
PUEBLO
ZIP
81005
Inspections & Citations
5 inspections · 4 deficiencies11/4/2025Licensure (Re-licensure) · ID XVSB11No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A relicensure survey was completed on 11/4/25. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
11/4/2025State Certification (Re-certification) · ID YRPZ11No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A recertification survey was completed on 11/4/25. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
8/11/2023Revisit: Licensure (Re-licensure) · ID RFBP12No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 8/14/23 for all previous deficiencies cited on 2/9/23. The agency is in compliance with all regulations surveyed.
Plan of correction
The state did not require a plan of correction for this citation.
2/9/2023State Certification (Re-certification) · ID 0PII11No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A recertification survey was completed on 2/9/23. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
2/9/2023Licensure (Re-licensure) · ID RFBP114 deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A relicensure survey was completed on 2/9/23. Deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
0662Prsnnl-Prsnnl Files Dept RvwS/S B▼
Findings
Based on observation, record review and interview, the residence failed to have personnel files for current employees available on site for Department review, affecting three of three sample staff (#1, #2, #3). Findings include:Chapter VII regulations governing assisted living residences, 2.45, defines "Staff" as employees and contracted individuals intended to substitute for or supplement employees who provide personal services. "Staff" does not include individuals providing external services. Chapter VII regulations governing assisted living residences, 7.12, each personnel file shall include, but not be limited to, written documentation regarding the following items: (A) A description of the employee or volunteer duties; (B) Date of hire or acceptance of volunteer service and date duties commenced; (C) Orientation and training, including first aid and CPR certification, if applicable; (D) Verification from the Department of Regulatory Agencies, or other state agency, of an active license or certification, if applicable; (E) Results of background checks and follow up, as applicable; and (F) Tuberculin test results, if applicable. On 2/9/23 at 9:00 a.m., the personnel files for the residence sample requested from the director of nursing (DON). On 2/9/23 at 9:15 a.m., the DON acknowledged that the residence did not keep the employee files on site and he had to go and get them for the review. He stated the office was located just a few minutes down the street from the location. On 2/9/23 at 10:30 a.m., the personnel files for residents #1, #2, and #3 received. On 2/9/23 at 3:50 p.m., the DON stated that he was not aware that the personnel files were expected to be onsite readily available for review.
Plan of correction · submitted by the facility
Golden Gate Manor has placed employees files who are assigned to the house with the date of hire, employee duties. Orientation and training CPR qmap verification back ground checks and TB test. These will be in a locked cabinet located in the nursing office allowing the managers to access only. The files will be accounted for and checked every month which will be added to the QMP monthly audit. These will be audited for a minimum of three months. Moving forward the director of nursing will ensure that the employee files are all kept up to date and located at the house in the nursing office.
0736Stff Rq-First Aid Stff CPR ListS/S B▼
Findings
Based on observation and interview, the residence failed to ensure a list of all staff who had current certification in first aid and/or CPR was placed in a visible location, affecting 13 current residents. Findings include:On 2/9/23 at 1:22 p.m., the director of nursing (DON) was asked to identify where the list of First aid/CPR certified staff was located,.. TOn 2/9/23 at 1:22 p.m. the DON stated that no list was posted. He said he was not aware a list of certified first aid/CPR staff was supposed to be visible and readily available to staff at all times.
Plan of correction · submitted by the facility
Golden Gate Manor has posted a list of all employees who all have a hands on course and Certification for CPR/ basic first aid. A Master list has been posted in the commons living areas for all residents to clearly view for review. A master binder has also been placed in the nurses station of all staff certification. Moving forward the Director of Nursing will ensure all staff are properly Certified with a Hands on course upon hire and as needed before any employee certification expires.
2516In Env-Gen SmkngS/S B▼
Findings
Based on observation and interview, the residence failed to ensure rooms occupied by smokers had fire resistant wastebaskets, affecting ten of ten residents who were identified as smokers (#4 - #13). Findings include: On 2/9/23 at 10:40 a.m., an environmental tour of the bedrooms of residents #4 - #13 revealed that none of the waste baskets in the resident's rooms were fire resistant. On 2/9/23 at approximately 4:00 p.m., the resident care coordinator stated she was not aware that residents who were smokers were required to have special fire resistant waste baskets. She and the director of nursing, both stated that none of the wastebaskets were fire resistant.
Plan of correction · submitted by the facility
Golden Gate Manor has purchased 14 fire resistant wastebaskets; one for each resident personal room. One fire resistant wastebasket will be placed in each residents room regardless if the resident smokes or does not smoke. A Smoking area safety form will be implicated for the staff to monitor and check the designated smoking area and rooms to ensure the safety of all residents, staff and environments daily moving forward as educated by the Director of Nursing.
2624In Env-Smkng Fire DspslS/S B▼
Findings
Based on observation and interview the residence failed to have a fire resistant waste disposal container in the designated outdoor smoking area, affecting 13 current residents. (Cross-reference Q2516)Findings include:On 2/9/23 at 8:33 a,m., an environmental tour of the residence's outdoor smoking area revealed metal coffee cans were being utilized for cigarette disposal. On 2/9/23 at 3:50 p.m., the director of nursing stated that he was not aware that the residence could not use metal coffee cans for cigarette disposal. He acknowledged that the smoking area did not have a fire resistant cigarette disposal container.
Plan of correction · submitted by the facility
(Cross-reference Q2516) A fire resistant waste disposal container has been purchased from Global industries. This has been placed in the outdoor smoking area for residents. This will be added the qmp form and audited for a minimum of three months.
Reportable Occurrences
2 records5/29/2024Physical Abuse · ID 24230663001Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 5/29/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported physical abuse of a client. During the course of the investigation the healthcare entity ensured the clients were separated before the police were notified. The clients were in a verbal altercation before Client (A) was pushed to the floor by Client (B). Client (B) was sent to the hospital for mental health treatment and hold, additionally Client (A) wanted to press charges after sustaining a bruise to their forearm. At the time of the report Client (B) had not returned to the facility. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 3/26/2025 · released to the public 4/2/2025.
12/9/2023Death · ID 23230663001Reported on time: No▼
Occurrence summary
DESCRIPTION OF OCCURRENCE: On 12/9/23, staff member (1) did hourly checks on residents and found a male resident (A) in his 50s not responding and they tried to wake him around 9:00 a.m. Resident (A) had his breathing machine on and this was removed by staff member (1) who saw the resident's lips were blue. Emergency services were called and gave instructions for staff to start CPR (cardo pulmonary resuscitation). CPR was initiated until the paramedics arrived and took over. The paramedics pronounced resident (A) as deceased a few minutes later. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, physician, and ombudsman. When reviewing the circumstances, staff reported the last time staff checked on resident (A) was at 8:00 a.m. and resident (A) gave a thumbs up at that time. The breathing machine was checked and noted to be functioning properly. Resident (A) was being followed by a nurse from a home health agency for additional support. He had a recent hospitalization on 12/6/23 for breathing issues and returned to the facility the previous evening 12/8/23. The facility investigation concluded procedures were followed by staff after his return from the hospital and when he was found unresponsive. It was not indicated that resident (A)’s death was suspected; however, the facility will continue to monitor residents who return from the hospital and provide skilled services as needed. The facility will also continue to have oxygen equipment serviced and monitored by the oxygen company.
DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.
Publication
Sent to facility 11/8/2024 · released to the public 11/15/2024.