Introduction As many as 50% of all nursing home (NH) residents meet the World Health Organization criteria for anemia. The objectives of this study were to determine the prevalence and appropriateness of prescribing and monitoring of erythropoiesis stimulating agents (ESAs) used to treat anemia in the NH setting. Methods Cross-sectional, one-month study of all NH residents in four community-based, university-affiliated NHs between January and February 2008. Residents were included in the analysis if they received at least one dose of an ESA during the study duration. Data collected through chart review included basic demographic information, ESA indication, ESA dosage, concurrent administration of iron supplements, hemoglobin (Hgb) monitoring, and blood pressure measurements. Results A total of 4.5% (22/485) of NH residents received at least one dose of an ESA. Residents who received ESAs had a mean age of 80.4 (± 14.5) years. Most residents who received ESAs were female (64% [14/22]), white (68% [15/22]), and had a mean weight of 72.0 (± 20.84) kg. Only 27% (6/22) of residents were prescribed an ESA for a FDA-approved indication. Darbepoetin alfa was the most commonly prescribed ESA (64% [14/22]) with a mean weekly dose of 70.8 (± 68.1) mcg, followed by epoetin alfa (37% [8/22]) with a mean weekly dose of 22,625 (± 21,232) units. More than one-quarter, (27% [6/22]) of those who received an ESA had a Hgb value ≥ 12 g/dL, the maximum recommended threshold for use of these medications. Of the 18 residents that had blood pressure measurements, 18% (2/18) were hypertensive. Conclusion Suboptimal prescribing and monitoring of ESAs were common in the NHs we studied. Future studies are needed to determine if the development and use of computerized decision support systems can improve prescribing and monitoring of ESAs in the NH setting.