When Amanda Coulson was a child, she visited her mother at work at a hospital in Little Rock, Arkansas. Doris Coulson was a nurse, and one memory never left her daughter. A code blue was called, and suddenly her mother was racing alongside a patient’s bed. 

“She jumped into the middle of the bed and was doing CPR in the bed as it flew down the hallway,” Amanda Coulson said years later in court. “I realized she didn’t play at work all day.”

That was the kind of caregiver her mother was: someone who understood what quality care meant because she had spent her life giving it to others. 

After Doris Coulson retired, she became a patient at a nursing home owned by Joseph Schwartz, a New Jersey businessman who was buying up nursing homes across the country. The staff wasn’t supposed to serve her solid food, but they did, and she died. Doctors told the family they found scrambled eggs in her lungs.

Nine years after Coulson’s death, President Donald Trump pardoned Schwartz in a federal case in which he had admitted to withholding $39 million in employee payroll taxes from his nursing home empire and diverting the money for other purposes. Schwartz’s lawyers argued that his actions were not an attempt at personal enrichment but to save his company. The White House said Schwartz was “an example of over prosecution” and argued that a third-party entity had managed the tax filings and that serving all three years of his prison sentence would have been detrimental for someone of his age and poor health. 

Behind the tax charge was a business that families and lawsuits said had left real people neglected, injured and dead. 

The Coulson family sued Schwartz and his company for wrongful death. Schwartz did not appear in court to challenge the case. Six years ago, a judge awarded Amanda Coulson and her sister and brother nearly $19 million. (He later claimed he never received key filings and had mistaken the complaint for the same lawsuit first filed in 2017. He argued the company that took over the home was the proper defendant.) Schwartz never paid. Amanda has since died.

Stories about pardons are often told as stories about presidential power — who got mercy, who had access, who persuaded a president to intervene. What drew me to Schwartz’s pardon was the people on the other side of that act of grace: people like Doris Coulson and her family, whose lives had already been shattered long before the White House celebrated Schwartz’s first Shabbat with his family after Trump freed him from prison and a top Justice Department official declared him “free to rebuild.” 

The pardon for Schwartz came while I was reporting on Trump’s broader clemency spree, which has favored allies, donors and other well-connected defendants, including people convicted in serious financial fraud cases. 

This pardon felt different to me. 

To understand the human toll, I turned to court records. In states where Schwartz owned nursing homes, I found harrowing accounts of patients suffering and insiders desperately trying to protect them as problems piled up. 

The damage reached workers, too: As facilities fell apart, some employees said they were buying food for residents out of their own pockets. Others were left with medical bills after insurance premiums were taken from their paychecks but the coverage was never funded.

And yet, Schwartz still appears to have money, perhaps even great sums. Lobbying disclosure forms showed he had paid more than $1 million to lobbyists to help secure his pardon. And even after his business collapsed, prosecutors said he still had $58 million in assets, though none was in his own name.

The White House has said the president does not issue pardons at the request of lobbyists.

After the pardon, Schwartz still had to return to Arkansas in late December to serve nine months in prison for defrauding the state’s Medicaid program.

I saw his return as a chance to speak with him. The prison system said I could reach him only by mail. In the first week of January, I sent a letter requesting an interview by phone, email or in person, noting that I could easily drive from my home in Missouri to meet him.

A lawyer for the Coulson family saw that same narrow window as a chance to do something more consequential: serve Schwartz with a subpoena for a deposition and records that might help locate his assets and force payment of judgments he had ignored.

The window for both of us closed almost immediately. One of Schwartz’s lobbyists had also been hired to seek relief for him in Arkansas. Within three weeks, the parole board released him.

My letter came back as undeliverable. The lawyer had no better luck tracking him down.

That episode helped me understand the story more clearly. At first it felt like a reporting failure. The more I sat with it, the more I realized that the missed window was actually a mirror of the broader story. Even after criminal convictions, civil judgments and years of litigation, Schwartz remained elusive to the people seeking answers or accountability. 

There was a machinery working to shorten his punishment. But nothing to help the victims.