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In 2003 in Carcer City, the story opens with a news anchor (Kate Miller) reporting on James Earl Cash (Stephen Wilfong), a death row prisoner recently executed by a lethal injection. In reality however, Cash awakens to hear a voice coming from an earpiece, revealing his lethal injection was only a sedative. The voice, who refers to himself as "The Director", promises Cash his freedom, but only if Cash follows his instructions. He must move through an abandoned section of the city being patrolled by a gang called "The Hoods", murdering them as he goes, all being filmed by CCTV. Cash successfully dispatches the Hoods, but despite the Director's promise of freedom, he is beaten and thrown into the back of a van by a group of private security experts called "The Cerberus".

Cash is then told by the Director that he reneged on their original deal and that he has more to do before the night is out. Cash is subsequently taken to various locations around the city and forced to face off against a series of increasingly dangerous gangs. First, he is pitted against a group of white nationalists and Neo-Nazis in a scrap yard. Then, he faces a gang of a former military turned mercenaries called "The Wardogs" in an abandoned zoo. Here Cash has to save members of his own family who have been kidnapped by the Wardogs and are being used as bait to lure him out. Following this, he fights a gang of Satanic Latino occultists and perverted pedophiles called "The Innocentz" in a derelict shopping center.

During this conflict, Cash discovers that the Director had his family killed despite his promise to let them go. After watching their deaths on a TV set up for him by the Director, Cash vows revenge as the Director coldly tells him "I'm all the family you need, now." After again facing the Innocentz in a graveyard and abandoned factory, Cash is forced to face off, in what is supposed to be the final scene of the film, against a gang of schizophrenic, sociopaths called "The Smileys" who have taken over an insane asylum. Here, Cash unexpectedly survives, killing the Smileys (including their leader dressed in a rabbit costume) and escaping the asylum after killing several Cerberus. As such, the Director deploys the remaining Wardogs, led by the vicious Ramirez (Chris McKinney), to hunt Cash down and kill him; from this point on, the Director no longer communicates to Cash.

As Cash escapes the asylum and enters an abandoned apartment complex, he is caught by Ramirez and the Wardogs, who decide to play a little game of cat and mouse; Cash manages to kill the gang and Ramirez before backup arrives. Upon fleeing the area, the journalist reporting on Cash suddenly arrives in her car and rescues him. She explains that the Director is actually Lionel Starkweather, a former film producer from Los Santos, who was popular in the 90s, but was forced to leave the industry due to a "scandal." The reporter has been putting together evidence about Starkweather's snuff movies for months, and now she has enough to expose him. First, however, she needs to retrieve some of this evidence from her apartment. Meanwhile, Starkweather orders the chief of the Carcer City Police Department, Gary Schaffer, to bring both Cash and the journalist to him, blackmailing him that he will expose his corruption to the Liberty City Supreme Court if he does not comply.

Protecting her from the police, Cash takes the journalist safely to her apartment, and from there, heads off to deal with Starkweather personally. Killing off several police officers, Cash then evades the SWAT teams, before making his way through a train yard, only to be cornered by more police and SWAT. They begin to beat him, and just as they're about to execute him, they are suddenly ambushed and killed by the Cerberers, who recapture Cash and bring him to Starkweather's mansion. There, they are about to kill Cash, but when Piggsy - a mentally disturbed, chainsaw-wielding psychopath, who wears a pig's head as a mask and was normally kept chained up in Starkweather's attic - breaks free. This distraction allows Cash to work his way through the garden and mansion, killing members of the Cerberus along the way. He finally reaches the upper levels of the mansion, where he and Piggsy stalk one another. Cash triumphs after luring Piggsy onto a grate that collapses under his weight. After using Piggsy's chainsaw to hack his way through the last of the Cerberus, Cash finally confronts Starkweather in his office. Upon disemboweling him with the chainsaw, Starkweather pleads with Cash to spare him by saying "Cash, I made you!", but Cash thrusts the chainsaw into his face, killing and impaling him.

Later, the media and the police arrive at the mansion, with the journalist exposing Starkweather's snuff ring and police complicity, and Schaffer is arrested for corruption and brought on trial in Liberty City for his actions. Cash, however, is nowhere to be found.