Lemon Grove Care & Rehabilitation Center
Citation Number: 090005704
Citation Date: 12/17/2008
Violation Date: 3/31/2008
Class: AA
Penalty: $ 80,000.00

On 3/31/08, a 74 year old resident with dementia caught on fire and sustained fatal injuries when her jacket caught on fire while she was lighting a cigarette in an outside courtyard on a windy day. She suffered severe burns that led to her death 10 days later. A resident witness reported it took staff at least 5 minutes to respond, by which time the resident was engulfed in flames. The resident was confused and had low safety awareness, yet the facility did not supervise her or monitor her while she was smoking. The facility was cited because it did not provide for the resident's safety.