While acknowledging the accused's diminished mental condition, the court ruled his mental capacity "was not so impaired" that he could not understand the consequences of his actions, Hahn Ji-Hyeong, the spokesman for the Gwangju District Court, told AFP by phone.
Identified only by his surname Kim, the man was one of around 70 resident, largely bed-ridden, patients at a special hospital for the elderly and chronically ill in Janseong County, 300 kilometres south of Seoul.
Although the blaze was brought under control within 30 minutes, many on the upper floor were unable to evacuate as the rooms filled with thick, acrid smoke.
A total of 22 died, most of them as the result of smoke inhalation.
Kim was taken into police custody the same day after CCTV footage showed him entering a storage room where the fire started.
He was eventually charged with arson and manslaughter.
The tragedy came as South Korea was still reeling from the loss of around 300 people - mostly schoolchildren - in a ferry disaster the previous month.
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