OBJECTIVES: To assess the rate of non-concordant use of oral anti-diabetic drugs (OAD) according to National Kidney Foundation (NKF) guidelines and drug package inserts (PI) among nursing home (NH) residents with diabetes and moderate to severe chronic kidney disease (CKD).  METHODS: Long-term care administrative database with medical and pharmacy claims information was analyzed. Residents with diabetes and moderate to severe CKD who remained in NHs for at least 90 consecutive days between 2008 and 2011 were selected. Residents with moderate to severe CKD was identifed if they had at least one glomerular filtration rate <60 ml/min/1.73m2in the 1 year prior to or during the 90-day period. Concordance was analyzed among residents that filled at least 1 prescription for OAD during the first 90-day continuous stay. If at least 1 of the OADs prescribed was not concordant to NKF or PIs, then that resident was classified as non-concordant.  RESULTS: Of the 730 diabetic residents with diabetes and stage 3-5 CKD, 186 residents used the OADs included in the NKF guidelines during their 90-day stay in a NH. Of the 186 residents, 135 (72.6%) received the OADs in accordance with NKF guidelines, and 77 (41.4%) received the medications in accordance with their respective PIs. There was no significant difference in the age, gender, and educational status and NH facility location distribution among NKF and PIs concordant and non-concordant groups. However, residents in NKF concordant group were more likely to be Hispanic (32.6 vs. 13.7%, p<0.05) compared to NKF non-concordant group.  CONCLUSIONS: The findings suggest that significant proportion of the OAD-treated residents with moderate to severe CKD, received at least one OAD prescription that was not concordant to NKF guidelines or PIs. Efforts should be made to more closely monitor OAD treatments of NH residents