Silent Hill: Homecoming tells the story of Alex Shepard, who awakens in a hospital after he hears a siren. Previously, he participated in the war, killed and saw many deaths, for which he was completely unprepared. At the hospital he is met by a doctor who does not say a word. He takes him to a separate room and goes to another place. Alex sees how medical staff brutally deal with patients.

Hearing more screams, the main character decides to get out of the straps binding his arms and legs. Wandering around the location, he encounters nurses whose faces are completely covered with bandages. They wield scalpels, and terrifying screams echo throughout the building. After a while, he meets his brother Joshua, who does not want to communicate and draws focusedly on an old canvas. The gameplay of Silent Hill is similar to the previous parts and takes place in reality between the fictional and real dimensions.

The central character will have to survive, facing monsters and enemies throughout his journey. The player can choose 1 of 2 difficulty levels: Normal and Hard. Difficulty affects the amount of medicine and ammunition scattered. The ward uses bladed weapons and firearms, and is also able to evade enemy attacks or get them with precise kicks.