Venous thromboembolism (VTE) is a significant, but underestimated, cause of morbidity and mortality in long-term care settings. VTE risk increases significantly with age and is further increased by comorbidities common to this group; however, advancing age and limited mobility alone are insufficient to warrant pharmacological prophylaxis. Recognizing those at increased VTE risk during an acute illness is crucial for appropriate and timely prophylaxis. Warfarin is used for the long-term secondary prevention of VTE, whereas unfractionated and low-molecular-weight heparins are used for primary prophylaxis. The elderly are at increased risk for bleeding complications, because of the high frequency of comorbidities and comedications. Attention to dosing is recommended for those with severely impaired renal function, low body weight, or perceived to be at high bleeding risk. This review addresses the role of risk assessment in the decision of when to provide prophylaxis to an individual in long-term care and highlights key management issues for those prescribed prophylaxis.