(A) The Commissioner or his/her designee may waive the applicability of one or more of the requirements imposed on the facility by 105 CMR 121.000 upon the finding that:

1. (1) compliance would cause undue hardship to the facility;
2. (2) the facility is in substantial compliance with the spirit of the requirement; and,
3. (3) the facility's non-compliance does not jeopardize the health or safety of patients, employees or the public.