Between February 2009 and November 2011, the Virginia Department of Health (VDH) was notified of acute hepatitis B virus (HBV) infections occurring in residents of four separate assisted living facilities (ALFs) in the Central Health Planning Region of Virginia. In each outbreak, the initial acute HBV infections were identified through routine viral hepatitis surveillance. VDH conducted epidemiologic and laboratory investigations of these reports. Infection control practices, particularly surrounding assisted monitoring of blood glucose (AMBG), were assessed by direct observation and staff member interviews. Further investigation and subsequent screening of ALF residents for hepatitis B uncovered additional acute HBV infections at each of the ALFs. ALF residents screened for HBV infection were categorized on the basis of published criteria as having acute or chronic infection, or being susceptible or immune to infection. All acute HBV infections were among residents receiving AMBG for management of diabetes. AMBG is safe when properly performed, but lapses in infection prevention practices during AMBG were identified at three of the four facilities. These outbreaks highlight the role of hepatitis B surveillance in detecting disease outbreaks and the need for a comprehensive strategy to prevent HBV transmission in ALFs, including vaccination, improved infection control oversight at ALFs, appropriate training of staff members performing AMBG, and prompt investigation of acute HBV infections.