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The death toll of COVID-19 patients at a Virginia nursing rose to 45 on Tuesday, prompting fears among the understaffed and underfunded facility that the worst is yet to come.

At the Canterbury Rehabilitation & Healthcare Center, just two nurses are looking after 40 patients at a time in the coronavirus quarantine wing. It’s the kind of facility that's particularly vulnerable to a coronavirus wildfire that has raged through the nation's frail, elderly long-term care populations, claiming more than 4,000 lives.

Nearly all of Canterbury's residents rely on Medicaid funding for the care of health problems that in many cases were the product of a lifetime of poverty. It lacks the amenities and space to keep people apart. And it lacks the pay to hire and keep enough staff.

"A publicly funded nursing home is a virus' dream," said Dr. Jim Wright, Canterbury's medical director. "It is the best place for a virus to be. People are close together. Their immune systems are compromised. It is just a tinderbox for that match."

Studies have shown nursing homes heavily dependent on Medicaid for revenue have fewer nurses and other staff per patient than average, and lower quality of care overall. And some of the biggest outbreaks so far have been at homes tied closely to the government payment program, including ones in Wayne, W.Va., and the Crown Heights section of Brooklyn in New York.

Canterbury, which had about 160 residents before its outbreak, was thrown into turmoil from the first COVID-19 diagnosis on March 18.

"You pick any element, or any arena in our facility that needed to be up and running at its best and nothing was," Wright said.

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Exactly how the coronavirus got into Canterbury is not clear. Tests were available but scarce at the beginning of the outbreak. Canterbury was not initially able to test all of its residents and staff because of guidance from state and national officials at the time.

By the time tests were conducted on everyone at Canterbury about two weeks after the first confirmed case, more than half the residents infected with coronavirus showed no symptoms of the disease.

"It's impossible to build walls around something that spreads so insidiously," said Dr. Danny Avula, the state health department's area director who has noted that Canterbury has been doing its best.

Canterbury’s death toll has surpassed the Life Care Center in suburban Seattle, where a special federal group of doctors and nurses was sent to help.

Since then, several governors have used their emergency power to do the same for their states. The National Guard was called in to evacuate a home in Tennessee, take over another one in Massachusetts and run tests at a third in Wisconsin. Special "strike teams" have also been tapped to run tests and ferry supplies to homes in Ohio, Indiana and Maryland.

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"Where is the state in some of this? Why wasn't more done on a state level, as well, to come in and take over the situation?" said Kim Thompson, whose 72-year-old mother Minnie Brown died at Canterbury. "There's lots of blame to go around."

The Associated Press contributed to this report.