Marlys Jacobsen, an 86-year-old who spent much of her life near Rock Lake, N.D., raised four children on her way to beating cancer three times. Her family remembers her as an expert baker, veteran cribbage player and doting grandmother.

In October, she came down with a sore throat, which was quickly diagnosed as COVID-19. Two hospitals and just weeks later, she was dead. Now her family is trying to make sense of their loss.

Jacobsen died in an Altru Health System bed in Grand Forks. And even though her family says they’re grateful for the staff’s hard work, they say they’re frustrated, too.

In a six-page letter they sent to Altru and provided to the Herald, Jacobsen’s family raised concerns about their mother’s stay. Most seriously, they said they’re concerned about the quality of care their mother received.

“She ordered breakfast and it arrived, but her family had to call the nurses’ station to track down her noon meal,” the letter reads, describing one of her earlier days in the hospital. “She received that noon meal — the same meal, not one that was remade, at 4 p.m., cold and soggy, and, via (video call), her daughter watched in horror as she gobbled it down. She was starving.”

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The letter goes on to describe the family’s similar concerns with how often she was bathed and her access to water — raising questions for them about the hospital’s preparedness for the pandemic.

One of the family’s other concerns was communication; they said that, after their mother was transferred to Altru from a bed in Cando, learning about her health status and navigating how and when they could visit her could be difficult and confusing.

“We absolutely acknowledge that your nurses and staff are doing the very best they can with the resources they have,” the family wrote. “But, in no uncertain terms you are systematically failing your front line workers at a time when it is imperative you support them in a big way.”

The family’s experience offers a window into the strained conditions in the North Dakota health care system, where medical staff have been fighting hard around the state to provide care despite an enormous influx of patients — both with COVID and with medical needs put on hold earlier in the pandemic.

In Grafton, the crowded critical access hospital had a bed in its chapel in mid-November. At Northwood’s Deaconess Health Center, CEO Pete Antonson worried recently that the state health care system was becoming so overburdened that “the balloon’s going to pop.”

The Jacobsen family’s experience invites the question: how much has that already begun to happen?

RELATED: Grand Forks region’s health care strained to tipping point

Janice Hamscher, Altru’s chief nursing officer, offered the Jacobsen family an apology in response to a copy of the family’s letter.

“Our hearts go out to the Jacobsen family for the loss of their loved one,” Hamscher said in a statement provided by an Altru spokesperson. “This absolutely was not the care experience they should have had, and for that, we are extremely sorry. We have met with family members, listened as they shared their experience, and based on their feedback are working to improve how we communicate with and support families of patients battling COVID-19.”

And while Hamscher stressed that Altru would work to improve — already boosting the minimum daily calls between COVID patients and their family from one to two — she also pointed out the extraordinary surge in COVID cases in North Dakota that have put significant strain on local health systems.

“Our region’s exponential surge in COVID-19 cases is stretching health care systems and our staff in ways unimaginable even five months ago,” Hamscher said. “We are constantly working to improve our processes and care delivery as we face new challenges the pandemic brings every day.”

That strain has been apparent around the state. Five dozen Air Force nurses were dispatched to North Dakota last month to shore up medical staff; Altru is receiving assistance from 10 of them. Hamscher, in a prior Herald interview unrelated to Jacobsen’s care, said that Altru’s nursing staff had already been thinned by COVID absences.

“What you have to understand is, you know, there’s a physical bed, and then we have to have the staff to go along with that,” Hamscher said last month. “So that has been a challenge for us.”

RELATED: Air Force Nurses look to ease the pressure on overburdened Altru staff

The statewide crisis makes it difficult to tell how much of the Jacobsen family’s experience is unique to Altru and how much of it is a byproduct of a system now overwhelmed by a pandemic. Altru laid off 167 staff earlier this year, but an Altru spokesperson said this week that no direct caregivers had been impacted in the move.

“We acknowledge that some of our support areas key to patient experience have had reductions on their teams,” said Annie Bonzer, the spokesperson. “We continue to assess our workforce needs and fill roles as we are able to ensure the great service our patients deserve is provided.”

And the Jacobsens aren’t the only ones frustrated by the crisis. Earlier in October, a Bismarck-area 19-year-old nearly died from kidney failure when medical professionals in that area — overwhelmed at multiple hospitals — simply did not have the resources to care for him immediately.

“I was terrified. I was scared,” Tammy Berger, the man’s mother, told Forum News Service in October. “I could see my son going downhill, and I was looking for somebody — anybody — to help him. This is America, a developed country, and I’m running around with my son looking for somebody to help.”

Jacobsen is one of more than 900 deaths in North Dakota this year from the coronavirus, and that number is all but certain to surpass 1,000 in coming weeks. But there is good news — the number of hospitalizations in the state appears to be steadily decreasing. According to the COVID Tracking Project, the average number of North Dakotans hospitalized for COVID has been tapering off for two weeks — from more than 400 to fewer than 350. It’s an early sign that nurses might soon be under less pressure.

“In the past week, we have seen a decrease in the number of staff that are being impacted by community spread,” Bonzer, the Altru spokesperson, said. “(It’s) a hopeful sign that the measures put in place by state and local officials are helping to ease the burden on our health care workers.”

That’s a reference to mask mandates and more, snapped into place by Gov. Doug Burgum and city leaders in Grand Forks and elsewhere, to curb the spread of the virus. For months, North Dakota had taken a more lax approach than other states — as Burgum stated a preference to appeal to North Dakotans’ judgment, rather than use his official powers to restrict public life.

But as the winter months set in, there’s also still wide concern that the worst is still to come, with Americans cloistered indoors as colder weather arrives.

“The reality is, December and January and February are going to be rough times,” Robert Redfield, the Centers for Disease Control chief, said in remarks widely reported earlier this week. “I actually believe they’re going to be the most difficult time in the public health history of this nation.”